Tzu Chi UK winter hardship support form (Cambs)
Your submission will be encrypted automatically and treated confidentially
Personal data (in accordance with GDPR)
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
-
Day
-
Month
Year
Date
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How many people are in your household?
*
How many people in your household are aged 0 - 4 yrs old?
*
How many people in your household are aged 5 - 10 yrs old?
*
How many people in your household are aged 11 - 18 yrs old?
*
How many people in your household are aged 19 - 69 yrs old?
*
How many people in your household are aged 70+?
*
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Has your situation changed recently?
*
I'm waiting for benefits
I've lost my job
I'm self isolating and unable to work
I have children at home (not at school)
My income has dropped
Other
Benefits
Council Tax Benefits
Income Support
Housing Benefit
Job Seeker's Allowance (JSA)
Disability Living Allowance (DLA)
Employment and Support Allowance (ESA)
Pension Credit
Other
Specify required support and reason for request
*
current or potential support from other agencies
How did you hear about us?
Community organisation
Family/friends
Internet
Other
Referrer name
First Name
Last Name
Referrer contact number
-
Area Code
Phone Number
Referrer contact Email
example@example.com
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We need your consent to be able to coordinate getting support to you. Please tick if you give consent for us to store and use your data for this purpose. You can withdraw consent at any time by emailing cambridge@tzuchi.uk
*
Consent given to use and store your data to get support to you
I confirm that the information I have given on this form is true and correct
Consent given to receive a call to discuss the support
*
Yes
No
Do you have anything else you would like to tell us?
Submit
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