Application Form for Admission as a Brother of Trinity Hospital

Data Protection Statement: The Hospital of the Holy and Undivided Trinity provides accommodation for single/widowed gentlemen who are aged over 50 years and live in the Retford or surrounding area. It is the Trustees’ responsibility to ensure that applicants for almshouses are suitably qualified under the terms of the charity’s governing instrument. Trustees therefore need to investigate the personal circumstances of applicants. The personal data supplied on this form, and other information relating to an almshouse appointment or your care management, will be held on file. Some details may be checked with relevant organisations, but none will be disclosed for any inappropriate purpose. You may have access to your personal information on request.

Full Name

Please let us know your name.

Full address including postcode

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Telephone

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Mobile

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Please let us know your email address.

Date of birth

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Are you

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Are you a car owner? if yes how long have you held a licence?

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Length of time at current address

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How far is your present home from West Retford?

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Is your present home: owned by you / rented / other, please give details

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If your present home is owned by yourself what would your plans be if offered an almshouse?

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What are your hobbies and leisure activities?

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Nest of Kin

Name of immediate next of kin / Emergency contact

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Address of next of kin

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Telephone of next of kin

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Mobile of next of kin

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Relationship to applicant

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Would your next of kin be anle to assist in case of illness or emergency?

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Church Connection

Are you a confirmed member of the Church of England? if no, what is your religious affiliation?

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Employment History

Are you currently employed?

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Name and address of employer

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Position held

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Length of this employment

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Are you retired? if yes, what was the date of your retirement?

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National Insurance Number

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Please give brief details of previous employment

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Legal Matters

Have you ever been bankrupt or had a court order for debt registered against you? if yes please give details

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Have you ever had a criminal conviction? if yes please give details

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Financial details

Do you own a house? if yes, what is its current value?

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What capital do you have?

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What pensions do you receive?

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Do you have any other sources of income? if yes please give details

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Medical Details (please note: it is essential that almshouse residents are able to care for themselves, with the assistance of family and social services as necessary).

Doctors name and address

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How long have you been a patient of this doctor?

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Do you smoke?

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Have you had any serios illnesses or medical conditions in the past five years? if yes please give details

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Would you allow the Trustee to consult with your GP (in confidence) in connection with your application?

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References (please give details of three people who can give a personal character reference, one of whom must be the clergyperson responsible for your Church of England parish. Referees will be asked to comment from their own knowledge of the candidate).

Name, address, telephone and email of your first referee

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Name, address, telephone and email of your second referee

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Name, address, telephone and email of your third referee

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I accept that if I am appointed I shall not be a tenant and I declare that the details above are correct to the best of my knowledge and belief and submitted in good faith. I confirm that I am able to look after myself, with assistance from Family and social services if necessary. Invalid Input

By submitting this form, you agree to allow us to use the information provided on this form for our own use. We will use the information to deal with your request and contact you. We do not pass your information onto any third parties.

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Click here to download an application form for admission as a Brother of Trinity Hospital.