Residency Form – The Great Hospital

Applicant 1 - Name

Applicant 2 (if applicable) - Name

IN CONFIDENCE
The Great Hospital / Registered Charity 211953
Personal Details

Address

Home Telephone Number

Mobile Telephone Number

Applicant 1 Nationality

Applicant 2 Nationality

Applicant 1 Place of Birth

Applicant 2 Place of Birth

Applicant 1 Date of Birth

Applicant 2 Date of Birth

Applicant 1 Age

Applicant 2 Age

Applicant 1 Previous Occupation

Applicant 2 Previous Occupation

Applicant 1 National Insurance Number

Applicant 2 National Insurance Number

Applicant 1 NHS Number

Applicant 2 NHS Number

Accommodation

1. Renting a privately owned property 2. Rent a local Authority property 3. Renting a Housing Association property 4. Living in a home that you own

If you have select 4 above, is this property mortgaged?

Yes No

Financial Details

Please indicate if weekly/monthly/annual

State retirement pension £

Other pensions £

Savings £

Investments £

Housing Benefit £

Other Benefits £

Attendance Allowance £

Medical Details

Do (either of) your have an illness or disability?

Yes No

Please provide details:

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

Yes No

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

Yes No

Can you (both) safely climb stairs?

Yes No

Do (either of) you use a walking aid?

Yes No

Any other medical details:

Name, Address & Phone Number of your current doctor

We may need to contact your GP as part of our assessment for residency.

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

1. Name

Relationship

Address

Postcode

Landline Telephone Number

Mobile Telephone Number

Email Address

2. Name

Relationship

Address

Postcode

Landline Telephone Number

Mobile Telephone Number

Emaill Address

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: here.