Energy Voucher Application

Copy to be added.

"*" indicates required fields

We can award an energy voucher to families caring for a child with a life-limiting condition, who are receiving support from a palliative care service, and who live in an area covered by Southern Gas Network (SGN). You can check whether this is available in your area using the SGN Postcode Checker. If you meet the criteria, we can offer a £99 voucher for use against your pre-payment meter or a £150 voucher to add to your energy account.

Energy account holder*
First name Surname

Relationship to child*

Which hospice or other palliative care service are you supported by?*

Do you live in a SGN area?*

No

Yes
Please check your postcode using the link at the top of this form.

Address*
Street Address Address Line 2 City/town/village County Postcode Country

Mobile number*

Email address*
Enter Email Confirm Email

Number of people living in your household*

Ethnicity
We use this to monitor how our services support different demographic groups.

Energy provider*

How do you pay for your energy?*

Account

Prepayment meter

If you use gas, would you like a carbon monoxide monitor?

No

Yes

We take your privacy seriously, and information about how we protect and use your personal data is set out in our privacy notice. You can withdraw or update your communication preferences at any time by calling 0117 989 7820, emailing supportercare@togetherforshortlives.org.uk.

CAPTCHA