Application Form

To apply for a stay at "A House for Karen" the following form is to be completed in full and e-mailed to stay@ahouseforkaren.co.nz
Click the link to download the A House for Karen Application Form in pdf format...

Application Form

...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 *:
  

 

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