Cold to Cosy Homes application

Surname*

First Name*

Title

Address line 1*

Address line 2

Town*

Postcode*

Primary Contact Number*

Secondary Contact Number

Best time to contact you (AM/PM/ANYTIME)*

Date of Birth*

Is there anyone (e.g. a carer or relative) who should be the primary contact used to arrange the call/visit?
If yes, please enter their details below (please note that our team will need to speak briefly to the named applicant to check consent for someone else to speak on their behalf)

Alternative Contact Name

Alternative Contact relationship to you

Alternative Contact Home Number

Alternative Contact Mobile Number

Alternative Contact Email Address

Local Area*

Occupancy*

Housing Association (if relevant)

Eligibility*

Please provide further details of your eligibility*

Referrer Name*

Referrer Organisation

Referrer Email*

Referrer Comments

If you are a homeowner, is your gas central heating broken?*

How did you hear about us / our energy advice?*

How did you hear about us - further notes

Are there any particular energy advice issues you would like advice on? (For example, high energy costs, draughts, dampness and condensation, energy debt, cold home, insulation, heating issues...)*

Please read the following privacy statement to the applicant, then tick the box below to confirm that they agree to sharing their information with us.
“Once your form has been submitted, a member of staff from the Cold to Cosy Homes team at Cumbria Action for Sustainability will phone you back, to check your details and book in your advice visit with one of our approved contractors. This call may include questions regarding your health and financial status and/or that of members of your household. At the end of the service you will receive a short survey.
Cumbria Action for Sustainability can collect and store this information because it is required to confirm your eligibility for the scheme and to help you access support available to make your home warmer and more comfortable whilst saving money on your energy bills. Your personal information will not be shared with or used by anyone outside this programme without your explicit consent, unless the law allows for the sharing of information for the purposes of prevention and detection of crime, or where you, or another person would otherwise be at risk of serious harm.
For more details of how Cumbria Action for Sustainability protects your personal information please read our Privacy Policy, available on our website"

Please confirm you have read the above information*

Please read the following privacy statement to the applicant, then tick the box below to confirm that they agree to sharing their information with us.

Do you consent to us contacting you for testimonial feedback following your home visit or call?
We use testimonials for marketing purposes. When you have given us your consent to be contacted and then to use your testimonial, you have the right to withdraw your consent. If your testimonial has been made public we cannot withdraw it at this stage but will make sure that it isn't used in any further marketing or reports to funders. To withdraw consent please email us at cosyhomes.org.uk*

Please read the following statement to the applicant, then confirm that they understand and that they give their consent:

I understand that Cumbria Action for Sustainability can collect and store my information because it is required to confirm my eligibility for the Cold to Cosy Homes with LEAP energy advice service. I consent to you sharing my details with Agility Eco, who run the LEAP programme. For more details of how Cumbria Action for Sustainability protects your personal information please read our Privacy Policy, available on our website.

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 consent to a member of staff from our partner LEAP contacting me by telephone in the next few days and understand that they may ask me further questions to confirm my eligibility for the schemes and arrange the appropriate next steps. I understand that this may include questions regarding my health and financial status and/or that of members of my household.

I understand and give my consent