Rockdale Housing Application Form - Long or Short-Term Residential Care in Central Sevenoaks

Application Form

Long or Short-Term Residential Care in Central Sevenoaks

Please use this application form to apply to move to Rockdale House

General Data Protection Regulation 2018

The information you provide will be held securely and in accordance with the General Data Protection Regulation 2018. Our Privacy Notice can be found here.

By completing this application form, I consent to information being shared with third parties if we need to make further enquiries in support of your application. This may include current or previous landlords, medical practitioners, or care managers.

Rockdale will not pass on information to third parties for any other reason.

Applicant’s address and contact details

Title

Title - Other

Surname

First name(s)

Date of birth

National Insurance Number

Ethnic origin *

Religion

Are you related to any member of the Associations Board of Trustees or Staff:

If yes, please give details?

Address, email and telephone numbers

Current address

Postcode

Home telephone number

Mobile or other contact number

Email address

Next of kin or representative’s address and contact details

Full Name

Current address

Postcode

Relationship to applicant

Telephone number

Mobile number

Email address

Could we contact you via email:

Would you like this person to be the main contact whilst your application is progressing:

Will this individual be contactable 24 hours a day?

Will this individual be your emergency contact?

Is there Power of Attorney in place prior to admission and if so, please can we have a copy?

Other contacts

Second point of contact:

Full Name

Current address

Postcode

Relationship to applicant

Telephone number

Mobile number

Email address

Third point of contact:

Full Name

Current address

Postcode

Relationship to applicant

Telephone number

Mobile number

Email address

Where do you live now?

Is your current permanent accommodation suitable for your needs?

If no, what difficulties do you have living there?

Community and home support

Do you have any help with domestic tasks, for example shopping, cooking and cleaning?

If yes, please give details of the help and who provides it?

Do you have any help with personal care, for example bathing, helping to get up in the morning and with meals?

If yes, please give details of the help and who provides it?

Do you have a Social Services care manager?

If yes, please give details of their name and contact details?

Your health

How would you describe your current state of health? Please give us details of your current medical conditions:

Please list the medications you are currently taking:

Please give the name of your doctor and their details:

Please give your recent medical history and any significant past history, including any operations you have had:

Do you have any DNR in place?

Additional information

Please use this space to provide any additional information:

Finances

Please provide details of your capital and income:

Do you own your own home?

If yes, please give its value and the amount of any mortgage or share of it which is yours:

Please list your savings and investments:

Please give details of your state and other pensions which you receive:

Please give details of any other sources of income, for example attendance allowance payments of investment income:

Please also include evidence of your finances to cover 2 years of Rockdale fees:

Signature

Date

Power of Attorney Signature

Signature

Date

General Data Protection Regulation 2018

The information you provide will be held securely and used in accordance with the General Data Protection Regulation 2018. Our Privacy Notice can be found below.

Please tick here to accept the terms

Yes