Service User Application Form Holiday Companion Care

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.* —Please choose an option—Select optionI doI do not

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*

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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?* —Please choose an option—Select optionYesNo

Do you use a commode?* —Please choose an option—Select optionYesNo

Do you use a Zimmer frame or any other walking aid?* —Please choose an option—Select optionYesNo

Do you use a wheelchair?* —Please choose an option—Select optionYesNo

Do you require lifting?* —Please choose an option—Select optionYesNo

Do you have a hoist?* —Please choose an option—Select optionYesNo

Do you require help with washing, bathing, dressing?* —Please choose an option—Select optionYesNo

Do you attend a Day Centre?* —Please choose an option—Select optionYesNo

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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?* —Please choose an option—Select optionYesNo

Will you and your companion need any vaccinations for this trip?* —Please choose an option—Select optionYesNo

Will emergency medical cover be in place?* —Please choose an option—Select optionYesNo

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?* —Please choose an option—Select optionYesNo

AMENITIES

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

Will carer/carers have access to Wi-Fi?* —Please choose an option—Select optionYesNo

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?* —Please choose an option—Select optionYesNo

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

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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:

—Please choose an option—The CLIENTA REPRESENTATIVE of the clientBOTH

Would you prefer to receive our correspondence by email?* —Please choose an option—YesNo

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.*

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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?

—Please choose an option—clientrepresentative from Step 4other

If 'other', please provide full details below

Would you prefer to receive our correspondence by email?* —Please choose an option—YesNo

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?* —Please choose an option—Select optionYesNo

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

Approved by POA or Representative (if Applicable)

Name:

Date:

Form was completed by: -

Name:

Date:

It would be helpful to us if you would tell us how you came to hear of Able Community Care. Please provide details:*

Details*

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