Application Form

To apply for a stay at "A House for Karen" the following form is to be completed in full and returned to P. O Box 300 Cambridge
or e-mailed to
Click the link to download the A House for Karen Application Form in pdf format...

Application Form Click to Download Reader

...or fill in the Online Application Form below.

E-mail applications can be made online from our web site: www.ahouseforkaren.co.nz. Hard Copy Forms are also available from:
The Cancer Society-Taranaki, 71 Lorna Street, Westown, New Plymouth. Hospice Te Rangimarie, 5 David Street, Westown, New Plymouth.

Please read our "Guidelines & Expectations" before filling out this form.

Patients Name *:
Patient Number (For Admin Purposes):
Taranaki Address:
Primary Nominee...
Nominated by:
Organization - Eg: Taranaki Hospice Cancer Society Other:
Contact Number:
Contact E-Mail:
Secondary Nominee...
Seconded by:
Organization:
Contact Number:
Contact E-Mail:


Doctors name *:
Contact number *:
Contact E-Mail *:
Type of illness *:


Sex *:
Age *:
Ethnicity (For internal statistic & future funding purposes only): European
  Maori
  Pacific Islander
  Asian
Ethnicity - Other:
Family Circumstances - 200 words or less *:
Purpose of Stay - 200 words or less *:
Other factors (Optional) - 200 words or less:
Intended number of group *:
Preferred Start Date (Within the next 3 months) *:
Intended number of nights (maximum of 6 nights) *:

The applicant &/or family representative are also asked to accept responsibility for the house during their stay and to abide by the rules and expectations of the Karen Cornelia Trust and ‘A House For Karen' Please ensure that you read through the ‘Guidelines and Expectations' that form part of the application, before signing and applying for a stay

Official Information Act 1982 & Privacy Act 1993: The information given on this form is confidential to the ‘A House for Karen' Trustees and members of the ‘A House for Karen' Selection Board, together with respective administration personnel. It will not be made available to any other persons or groups and will not be used for any other purposes. I hereby authorise and agree to the above details being verified with my doctor and the aforementioned parties, nominee & seconder.

I agree to the above details: Yes
No
Date *:
Image Verification Code: Image Verification
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‘Guidelines and Expectations’ when staying at the house

On November 6th 2003 Karen Van Dillen lost her fight with cancer, aged 44.
In her memory, a charitable trust (The Karen Cornelia Trust) ‘KCT’ was set up by her husband Ron with the
idea of building a holiday home as a haven for families suffering with cancer or any other serious illness.
The Trustees kindly request that people staying at the house respect the property and abide by a few
simple guidelines to ensure that the house is being used appropriately in the spirit that it was established.

  • No smoking is allowed in the house. If smoking in the grounds, in consideration for other users,
    please dispose of cigarette butts thoughtfully.

  • No hangis or fires are allowed in the grounds or on the adjoining beach.
    Please contain fires to the Fire pit which has been specifically designed for this purpose

  • Remove all footwear at the door to avoid sand and soil being carried through the house

  • Please ensure that the ‘Lock Up Check List’ is carefully checked off when vacating the property
    (Copies of the list are near the door into the laundry)

  • No tents, awnings or structures are to be erected in the grounds of the property

  • No Pets

  • No parking on the grassed or planted areas

  • Large gatherings of people, over and above the applied for numbers for the stay, are not permitted

  • Excess alcohol consumption and loud music is to be discouraged in respect for the property.

  • Dry store groceries and supplies not used during a stay are to remain at the house for the benefit
    of future users

  • Please leave the house in a clean and tidy manner as it was found, including replenishing used
    firewood and follow the ‘Lock Up Check List’ provided.
    (Bed linen and towels will be washed at the end of the stay by a commercial firm)

Please report any breakages, damage or faults to the administration office of KCT

Ph: 06 759 8940

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