Organisation Referral FormCommunity Support Referral PUBLIC SUGGESTION FORM COMMUNITY SUPPORT ORGANISATION REFERRAL FORM Referral from a Community Organisation Please complete the form below Refer someone for supportCommunity Organisation Name: *Organisation making support requestOrganisation Registration Number:Charity/ C.I.C Company Registration NumberContact: *Full NameContact Number: *Mobile or OfficeContact Role: *Contact's role within the organisationOrganisation Website:(If the organisation has one)Contact Email Address: *Confirm Email Address *Address *Town/ City *County *Post Code *I CONFIRM THE ORGANISATION INFORMATION IS CORRECT, I ALSO CONFIRM... *I have read and agree to the privacy & cookies policy and Renovate Community Repair's terms and conditions documentation (published at the bottom of RCR'S website)Applicants Full Name: *Applicant Phone No: *Applicant Email Address: *Confirm Email Address *Applicant Date of Birth *Applicant Preferred Contact MethodPhoneEmailOrganisation ContactApplicant Address *Town/ CityCountyPost CodeDoes the applicant have vulnerabilities?Helps with prioritisationAt Risk GroupDisabilityElderly PersonHealth ConditionLow IncomeSingle ParentOtherI CONFIRM I AM APPLYING WITH PERMISSION & ON BEHALF OF THE APPLICANT AND THEIR DETAILS ARE CORRECT, I ALSO CONFIRM... *I have read and agree to the privacy & cookies policy and Renovate Community Repair's terms and conditions documentation (published at the bottom of RCR'S website)Repairs/ Maintenance Support Requested *Describe the issuesHow long has the problem persisted< a week< a month< 6 months6 months +Date of Request *Date of support requestUrgency(to help with prioritisation)LowMedHighRisks to Applicant *(if the problems are not addressed)Barriers/ Constraints *E.g. landlord permission, financial cost, access, physical barriersHousehold Composition *So we may understand the scale of need & prioritiseI CONFIRM THE APPLICANT HAS CONSENTED TO BE CONTACTED BY RCR IN RELATION TO THE INFORMATION IN THIS FORM, I ALSO CONFIRM *I have read and agree to the privacy & cookies policy and Renovate Community Repair's terms and conditions documentation (published at the bottom of RCR'S website)Submit
