ACDT Partner Referral Form

Ardrossan Community Development Trust have been awarded anchor funding from the Lottery Community Fund to support residents of Ardrossan (KA22 postcodes) during the current Cost Of Living & Energy Crisis. We want to assist all residents and there is no criteria other than a recognised need from our referring partners to access assistance.

Please complete the form below and our staff will deal with the request received. If you require any further information please contact our staff using the details below:

Eddie Gibb, Development Officer:
(t): 01294 608177
(e): developmentofficer@ardrossantrust.org
Reception Staff:
(t): 01294 608162
(e): staff@ardrossantrust.org

Referring Agency Details

Referring Agency Name *

Agency Contact Name *

First

Last

Email *

Phone *

Date of Application

Today's Date

Client's Details

Name *

First

Last

Client Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Client's Phone Number *

Client's Email

Client's DOB:

How many Children under the age of 16 in the household?

Client Needs:

Fuel Vouchers
Food Vouchers
Winter Clothing
Low Energy Applicance
Small Household Items

Please select all that apply.

Do you require Breakfast Club Vouchers?

How Many Children Under 16 In Your Household?

Breakfast club vouchers can only be provided for children under the age of 16

Is the Fuel Supply Pre-Payment or Not

Fuel Supply IS prepayment
Fuel Supply IS NOT prepayment

Which Payment Method Would You Prefer

Paypoint
Post Office

Winter Clothing Needs:

Jacket
Jumper
Cardigan
Hat
Scarf
Gloves

Low Energy Applicance Needs:

Slow Cooker
Microwave
Air Fryer

Small Household Item Needs:

Cutlery
Pots and Pans
Dishes
Pillows
Duvet
Sheets and Pillow Cases

Please describe why you are referring the client to ACDT, please be as detailed as possible. *

This area must be competed at all times for the referral to be accepted by ACDT

Signature *

By typing your name in this box you are giving permission for the provision of information relating to my advice needs to the ACDT Referral Team. I understand and agree that all information given will be available to both of these parties at all times for the purpose of assisting me in my Energy bills.

Date of Submission

Today's Date