Short Stay Respite Care

To be completed by the Applicant or the Power of Attorney as applicable

Physical, electronic and procedural safeguards will protect your personal information.

Personal Info

Nightingale Hammerson is a care home for those of the Jewish faith, or those who have lived a Jewish lifestyle, do you consider yourself to be Jewish?(Required)

Yes

No

Name(Required)

Title First Middle Last

Maiden/ Other name

Marital status(Required)

Single

Married

Partner

Widowed

Place and Country of Birth(Required)

Date of Birth(Required)

Nationality(Required)

NHS Number(Required)

Home

Mobile(Required)

Permanent Address(Required)

Street Address Address Line 2 City Post Code Country

Is your present address different?(Required)

Yes

No

Present Address (if different)(Required)

Street Address Address Line 2 City Post code Country

Reason/s for requiring short stay/ respite care(Required)

Name of local authority where you/ the applicant normally lives(Required)

Dates for suggested stay(Required)

Is there a Power of Attorney (POA) in place?(Required)

Yes

No

If yes what type of POA is it?(Required)

Lasting Power of Attorney (LPOA)

Enduring Power of Attorney (EPOA)

If LPOA, please tick what LPOA is for:(Required)

Health & Welfare

finance & Property

Please attach copy of EPOA/LPOA if available

Max. file size: 512 MB.

Please state the holders of EPOA/LPOA

Name(Required)

First Last

Type of LPOA held(Required)

Address(Required)

Street Address Address Line 2 City Post code Country

Phone(Required)

Email(Required)

Name

First Last

Type of LPOA held

Address

Street Address Address Line 2 City Post code Country

Phone

Email

Has a Deputy been appointed by the Court of Protection?(Required)

Yes

No

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City Post code Country

Phone(Required)

Email(Required)

Mental Capacity

Do you/the applicant have the capacity to make the decision regarding this placement?(Required)

Yes

No

If NO, who is making the decision regarding residency?

Name(Required)

First Last

Relationship to applicant(Required)

Address(Required)

Street Address Address Line 2 City Post code Country

Phone(Required)

Email(Required)

Have you/the applicant ever been subject to a mental capacity assessment?(Required)

Yes

No

If YES, what was the outcome of the assessment? Please provide relevant paperwork

File

Max. file size: 512 MB.

Have you/the applicant ever been subject to a Deprivation of Liberty Safeguards (DOLS)?(Required)

Yes

No

If YES, please provide relevant paperwork

Max. file size: 512 MB.

Conditions of entry

I hereby declare that I understand and agree to the above conditions of entry and that the statements I have made are true.

Signatory name of applicant/power of attorney (Please state which)(Required)

Date(Required)

This application will not be accepted unless signed by the Applicant / Power of Attorney.

Tel: 020 8673 3495 or email residentsservices@nightingalehammerson.org

Signature

Short Stay Respite Care

Application for Respite Short Stay Care

To be completed by the Applicant or the Power of Attorney as applicable

Personal Info

GENERAL PRACTITIONER/ DOCTOR

FIRST POINT OF CONTACT/NEXT OF KIN

NEXT OF KIN 2

NEXT OF KIN 3

NEXT OF KIN 4

POWER OF ATTORNEY

Please state the holders of EPOA/LPOA

Mental Capacity

If NO, who is making the decision regarding residency?

ACTIVITY DETAILS

Conditions of entry

This application will not be accepted unless signed by the Applicant / Power of Attorney.