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: https://www.greathospital.org.uk/wp-content/uploads/2018/05/GDPR-Privacy-Notice-for-Residency-Applicants_LP.pdf