Southampton Church Rent Deposit Scheme Referral Form
Please insert the email address of the person making the referral
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Email *
Application Type *
Referred by (all applications must be made by a recognised referral partner) *
If 'Other', please give details *
First Name *
Of the person being referred
Surname *
Of the person being referred
Address *
Of the person being referred
Postcode *
Of the person being referred
Phone No.
Of the person being referred
Email *
Of the person being referred
Gender *
Of the person being referred
DOB *
Of the person being referred
MM
/
DD
/
YYYY
Relationship Status *
Of the person being referred
Dependent Children *
Of the person being referred
If 'Yes', please provide their ages and gender.
Are you in receipt of any government benefits? *
Required
What contribution are you able to make towards paying for a deposit? *
Are there others who can help contribute towards paying a deposit? *
Brief description of reasons for applying for assistance from SCRDS *
What is your connection to Southampton *
Name of the organisation making the referral *
Name and role of the person making the referral *
Email address of the person making the referral *
Case Type *
Further comments
e.g. Is the client a care leaver? Have they spent more than 3 months in a homeless hostel? Any other information that may be useful
Equality and Diversity Monitoring
How would you descibe your ethnicity? *
Do you consider yourself to have a disability? *
If 'Yes', please provide details...
Do you have any Criminal Convictions? *
If 'Yes', please provide details...
Permission to store your data
City Life Church have a legitimate interest to use the data provided on this form in order to administer the Southampton Church Rent Deposit Scheme.  Data will not be shared with third parties unless permission is granted to do so and only for the purposes of trying to help clients meet housing needs for which they have been referred.  
Data will be securely stored for a period of 6 years.
In order to monitor the scheme we also request certain additional sensitive data on ethnicity, disability and criminal convictions. We are required by law to ask for your permission to record and store these details along with your housing enquiry.
I give my consent to SCRDS to record sensitive personal information about me *
Permission to share your data with other advice providers
Everything you tell us will be treated confidentially. However, in certain exceptional circumstances, where there are indications of serious danger to themselves or to others; or indications of crime being committed, then we reserve the right to break confidentiality.

We may suggest that you go to another organisation for advice because they will be more able to help you with all or part of your problem. We may be able to refer you to them and help you get an appointment. Ideally we would also give them the information you have given us.

If you give consent below, you are agreeing that SCRDS may:

- refer you to other advice providers;

- make appointments with other advice providers;

- share your personal information with other advice providers so that they have initial information about you and your possible problem.
I give my consent to SCRDS sharing my peronal information with other advice providers for the purposes of efficient appointments and referrals to help me with my problems. *
Have you received support from this scheme in the past? *
How did you hear about the Southampton Church Rent Deposit Scheme? *
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