Cold to Cosy Homes self-referral

Cold to Cosy Homes application

Please complete this form if you are applying for yourself.

Local council *

Your home is... *

Housing association (if relevant)

Eligibility type *

Postcode *

Address line 1 *

Address line 2

Town *

Title *

First Name *

Surname *

Primary contact number *

Secondary contact number

Is there anyone (e.g. a carer or relative) who should be the primary contact used to arrange the visit?
If yes, please enter their details below:

Title
First name
Surname
Alternative contact number (home)
Alternative contact number (mobile)
Email

Primary contact

If you own your own home AND your gas central heating is broken, then please select Yes. Otherwise please select No.

Gas Central Heating broken *

Yes No

How did you hear about this scheme?

How heard

Other how heard

I consent to you sharing my contact information with Cumbria Action for Sustainability and AgilityEco who are running the LEAP programme with the support of the council / housing association. I understand that a member of staff at Cumbria Action for Sustainability and the LEAP contact centre will telephone me to ask me further questions to confirm my eligibility for the scheme and arrange a home energy visit. I understand that this may include questions regarding my health and financial status and/or that of members of my household. I understand that my personal information will not be shared with or used by anyone outside this programme without my explicit consent unless the law allows for the sharing of information for the purposes of prevention and detection of crime or where I, or another person would otherwise be at risk of serious harm.

I give consent *

Yes

CiviCRM

Cold to Cosy Homes application