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. Proiority 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 Pricacy legislation.

Name

First Last

Date of Birth

MM / DD / YYYY

Address

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

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 Consession 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

Relationship to applicant

Where did you hear about the service

The Home Modification and Maintenance Service wishes to advise you that stastistical information will be passed on to the NSW Department of Ageing, Disability and Home Care in a way that protects your identity.

This information is needed to plan or the future service needs of people who are aged, have disabilities or their carers. Your details will not be passed on without consent UNLESS there are concerns for others or your safety or if legally required.

You have the right to withdraw consent and your personal file may be viewed if you ask to see it.

By ticking the box below will confer your consent UNLESS you tell us otherwise.

I declare the information provided is correct

I agree

OFFICE USE ONLY

Priority Rating

High

Medium

Low

Service Eligibility

Yes

No

Service Agreement offered

Yes

No

Playced on waiting list

Yes

No

Letter notifying ineligibility sent

Yes

No

Letter notifying placed on waiting list sent

Yes

No