Care application

Please answer all questions in full – all information will be treated in confidence.

    Your details

    Next of kin

    General practitioner / social worker

    General practitioner

    Social worker

    Your medical history

    HOW DID YOU HEAR ABOUT US?

    Equal Opportunities Monitoring

    Thorngate Churcher Trust is committed to providing sheltered housing and residential care to the diverse population we serve. It is vital that we monitor and analyse diversity information so that we can ensure that our processes are fair, transparent, promote equality of opportunity and do not have an adverse impact on any particular group. Your cooperation in providing us with accurate data will ensure that we not only meet our legal obligations, but even more importantly, will result in us designing and applying policies and processes that attract a balanced and diverse community to enjoy the benefits of Thorngate Living. Any information provided on this form will be treated as strictly confidential and will be used for statistical purposes only. No information will be published or used in any way which allows any individual to be identified.

    Any information you provide here will be used for monitoring purposes only – if you need a ‘reasonable adjustment’, then please follow the additional separate process. We will take reasonable steps to meet your particular needs.

    HOW WOULD YOU DESCRIBE YOUR NATIONAL IDENTITY?

    HOW WOULD YOU DESCRIBE YOUR ETHNICITY?

    White

    Mixed / multiple ethnic groups

    Asian / Asian British

    Black / African / Caribbean / Black British

    Other ethnic group

    Confirmation of signature

    To the best of my knowledge and belief the statements made in this application are true and correct.

    We will use your personal information to decide whether to offer you accommodation and care. If successful in becoming a resident at Thorngate Churcher Trust we will use your personal information in order to deliver an efficient and effective service as a registered provider of housing and social care. We may share your personal information with Hampshire County Council, Gosport Borough Council, Adult Services, your GP and/or the NHS only if sharing your personal data complies with our data protection policy. We will not share your personal information, without your consent, with any other organisation except to help prevent fraud or if required to do so by law. You have the right to request a copy of the personal information we hold about you. If you would like a copy of some or all of this please contact us at: Clare House, Melrose Gardens, Gosport, Hampshire PO12 3BZ.

    Please fill in your name and tick the following to authorise being kept on our waiting list and authorise us to keep in contact with you about other services we offer at Thorngate Churcher Trust

    Yes please I would like to be contacted about services offered by Thorngate Churcher Trust by the following methods