Service User Application Form Holiday Companion Care

Get in touch today

Join our team

Step One - Personal Details and Permission

Step Two - State of Health

Step Three - Holiday Companion Information

Step Four - Correspondence and Emergency Contacts

Step Five - Payment and Additional Details

Service User Application Form Holiday Companion Care

Important Details About This SERVICE USER ACCESS FORM

Please complete giving details of the person requiring our holiday companion service. You are under no obligation and will not incur expense until such time as you agree to commence with our services after detailed discussion with us.

Your Data

To process your application, we need to record and store your details on our secure database. If this basic level of permission is not granted, then we will not be able to continue with this application.

Please confirm below that you give Able Community Care Ltd permission to store your details.*

Able Community Care Ltd promises never to share or sell your information to other organisations or businesses and you can opt out of our communications at any time by phoning 01603 764567, writing to Able Community Care, The Old Parish Rooms, Whitlingham Lane, Trowse, Norwich, NR14 8TZ or by sending an email to info@ablecommunitycare.com.

Your information will be kept for 1 year after the end of registration unless you ask us to remove it from our records. After this time, the information we keep about you will be minimised and archived.

If you would like to read our full Privacy Statement, please request a copy by contacting us as above.

Prospective Client

Surname*

Title*

Date of Birth*

Forenames*

First Language*

Address*

Post Code*

Tel. No.*

E mail*

Service User Application Form Holiday Companion Care

Step 2 of 5

Please complete all fields with a *.

State of Health of Client

Please give full details of any health problem, any named disease and also details of any special dietary requirements.*

Health Problems, Diseases & Dietary Requirements*

Weight*

Height*

Is help required during the night?*

Times per night

Times per week

Do you use a commode?*

Do you use a Zimmer frame or any other walking aid?*

Do you use a wheelchair?*

Do you require lifting?*

Partial / Total lifting

Do you have a hoist?*

Name of Manufacturer

Model

Date of last maintenance check

Do you require help with washing, bathing, dressing?*

Details

Do you attend a Day Centre?*

Service User Application Form Holiday Companion Care

Step 3 of 5

Please complete all fields with a *.

HOLIDAY COMPANION INFORMATION

Please state your holiday destination: - (Dates and length of stay)*

Are you travelling abroad?*

If travelling abroad, please state travel and flight details: -

Will you and your companion need any vaccinations for this trip?*

If so, what will they need?

Will emergency medical cover be in place?*

If Yes, please give details: -

ACCOMMODATION DETAILS

Describe the accommodation that you and your carer/companion will be staying in e.g. hotel/cruise.*

Will the carers have their own room?*

AMENITIES

Please state the amenities that would be available in the holiday accommodation:*

Will carer/carers have access to Wi-Fi?*

Drivers: Please note: We cannot always guarantee to provide carers who are car owners/drivers or who have an international driving licence, but we will make every effort to do so if required.

Smoking, would you prefer a non-smoker?*

GENERAL INFORMATION

The Agency makes every effort to obtain a ‘good match’ between clients and holiday companions and, in order to assist us in this, it will be helpful if you can give us details of interests, hobbies, your previous occupation and your religion if any:

Details

Service User Application Form Holiday Companion Care

Step 4 of 5

Please complete all fields with a *.

Correspondence

We confirm all bookings in writing or email. Should correspondence be sent to:

If correspondence has to be sent to a Representative, please give the following full details:

Surname and Title:

Initials:

Status (i.e. whether a relation, solicitor, bank manager etc.):

Address:

Post Code:

Tel. No.:

Email:

Would you prefer to receive our correspondence by email?*

Emergency Contacts

Please give the name and telephone number of any person who should be contacted in an emergency.*

Name*

Relationship*

Tel. No.*

E mail

Your Doctor

Please give the name, address and telephone number of your Doctor.*

Name*

Address*

Tel. No.*

Service User Application Form Holiday Companion Care

Step 5 of 5

Please complete all fields with a *.

Payment of Accounts

To whom should the Agency’s accounts be sent?

If 'other', please provide full details below

Surname and Title:

Initials:

Status (e.g., relation, solicitor, bank manager):

Address:

Post Code:

Tel. No.:

Email:

Would you prefer to receive our correspondence by email?*

Prescribed Medication

Please only sign this if you require Assistance with your Medication

(Please note we do not give injections)

Do you require assistance with your medication?*

Do you give full permission for your holiday companion to administer any medication prescribed by your GP?*

Are you the client or advocate please select?*

Name:

Date:

General Information

The Agency makes every effort to obtain a ‘good match’ between clients and holiday companions and, in order to assist us in this, it will be helpful if you can give us details of interests, hobbies, your previous occupation and your religion if any:

Details