EmailMe Form - LAWN MOWING SERVICE APPLICATION

This Lawn Mowing service is provided to the HACC target population of the frail aged and younger people with a disability and their carers. Priority for service is directed to persons within the target population most in need.

All information is treated as confidential and is treated in accordance with Privacy legislation.

Name

First Last

Date of Birth

DD / MM / YYYY

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

Do you identify as an Aboriginal or Torres Strait Islander person

Yes

No

Country of birth

Ethnicity

Language spoken

ARE YOU?

Frail aged (over 65 with moderate to severe disability)

Yes

No

A younger person with moderate to severe disability

Yes

No

The carer of a person with moderate to severe disability

Yes

No

Do you have or do you care for someone who has dementia

Yes

No

Do you live with an aged or disabled carer

Yes

No

Do you have a health related condition that limits your mobility

Yes

No

Do you receive other services such as Home Care, MOW, Veterans Affairs Home Care, District Nursing

Yes

No

Have you been hospitalised multiple times in the last 6 months

Yes

No

Briefly detail why you or a member of your household cannot mow the lawns.

USUAL LIVING ARRANGEMENTS

Do you live

With spouse/partner ONLY

Alone

With other relatives/persons

Do you:

Own your own home

Private Rental

Public Tenant

SOURCE OF INCOME

Do you receive a Government pension

Part pension

Full pension

Pension type

Pension number

Other (specify)

Pension Concession Card Number

Other (specify)

HOW YOUR LAWNS ARE CURRENTLY MAINTAINED

Who mows the lawn

How long does it take

How much does it cost

Work requested (briefly describe the work required)

EMERGENCY CONTACT PERSON/CARER

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region