Residency Application


IN CONFIDENCE
The Great Hospital /Registered Charity 211953:

Personal Details

  

  

  

  

  

  

  

  

Status - MarriedCivil PartnershipSingleDivorcedSeparatedWidowed

Accommodation


If you have selected 4 above, is this property mortgaged? YesNo

Financial Details

Please indicate if weekly/monthly/annual

Income

Medical Details

Do either of you have an illness or disability? YesNo

If YES, please give details below-

Do (either of) you have a sight impairment, not corrected with glasses?YesNo

Do (either of) you have a hearing impairment, not corrected with an aid?YesNo

Can you (both) safely climb stairs?YesNo

Do (either of) you use a walking aid?YesNo

Name, Address & Phone Number of your current doctor

We may need to contact your GP as part of our assessment of needs. This is especially important for any admissions to our “Assisted Living Unit”.

Please indicate below your interests & any activities that you take part in

Please give any supporting information regarding your application

Next of Kin / Or someone who can be contacted in an emergency

Please supply two names

Lasting Power of Attorney

Please give details below

How did you hear about the Great Hospital?

 

The Great Hospital collects and processes personal data relating to applications for residency and is committed to being transparent about how it collects, stores and uses that data and in meeting its data protection obligations under data protection legislation including the General Data Protection Regulation (GDPR). Please read our privacy notice for residency applicants for further information on how and why we collect and use your personal information, both during and after the application process.
This can be found here: http://www.greathospital.org.uk/wp-content/uploads/2018/05/GDPR-Privacy-Notice-for-Residency-Applicants_LP.pdf