ADMISSION REQUEST. Before signing this Admission Request, please read the Residence Terms set out in Part 2 on page 8 onwards. (Please ask for an explanation of any areas that you do not understand). The following details, together with the Residence Terms in Part 2, form the Agreement which applies to the admission of the Resident named below as a Resident of the Care Home. Resident’s Name: Mr/Mrs/Miss/Ms/Dr/Rev/Other Care Home Name: Date of Admission: / / Resident’s Address: Date of Birth: / / Method of payment: Direct Debit By the time of your admission to the Care Home the Resident and any Third Party Contributor must have a direct debit in place for payment. Name and Address of Resident’s Attorney under a power of attorney (if any) or Resident’s Representative: Name: Address: Interest is charged on late payments at the rate of 4% above HSBC Bank’s base rate from time to time. Post Code: Telephone No: Email Address: Residential Fees (gross weekly) £ Liability for funding/sources (weekly) Type of PoA: for Residential Fees Resident £ Continuing: Welfare: Combined: Please note that a copy of your PoA may be Third Party Liability £ requested by us. OR Council/other Public Funding £ Name and Address of Guarantor: (including any contributions to Council Funding ) Total net weekly fee (being Resident Fees) £ Deposit £ (2 x net weekly fee, i.e. net of approved Public Funding) Advance Fee £ (4 x net weekly fee, i.e. net of approved Public Funding) Postcode: Telephone No: Email address: Name and Address of Third Party Contributor
ADMISSION REQUEST. Please read the Residence Terms set out in Part 2 below carefully before signing this Agreement (which, together with this Admission Request form part of the contract between us). Please ask for an explanation of any areas that you do not understand. The following details, together with the Residence Terms in Part 2, form the Agreement which applies to the admission of the Resident named below as a Resident of the Care Home. Resident’s Name: Mr/Mrs/Miss/Ms/Dr/Rev/Other Resident’s Address: Date of Birth: / / Method of payment: Direct Debit By the time of your admission to the Care Home the Resident and any Third Party Contributor must have a direct debit in place for payment. Residential Fees (gross weekly) £ Liability for funding/sources (weekly) for Residential Fees Resident Third Party Liability OR Council/other Public Funding (including any contributions to Council Funding ) £ £ £ Total net weekly fee (being Resident Fees) £
ADMISSION REQUEST. Please read the Residence Terms set out in Part 2 below carefully before signing this Agreement (which, together with this Admission Request form part of the contract between us). Please ask for an explanation of any areas that you do not understand. The following details, together with the Residence Terms in Part 2, form the Agreement which applies to the admission of the Resident named below as a Resident of the Care Home. Resident’s Name: Mr/Mrs/Miss/Ms/Dr/Rev/Other Care Home Name: Date of Admission: / / Resident’s Address: Duration of stay Date of Birth: / / Method of payment: Direct Debit 4 weeks after your admission to the Care Home the Resident and any Third Party Contributor must have a direct debit in place for payment. Interest is charged on late payments at the rate of 4% above HSBC Bank’s base rate from time to time. Long Stay (more than 28 days) Short Stay (complete period below) Days/Nights Departure Date / / Name and Address of Resident’s Attorney under a power of attorney (if any) or Resident’s Representative: Name: Address: Post Code: Telephone No: Residential Fees (gross weekly) £ Liability for funding/sources (weekly) for Residential Fees Resident Third Party Liability OR Council/other Public Funding (including any contributions to Council Funding ) £ £ £
ADMISSION REQUEST. Before signing this Admission Request, please read the Residence Terms set out in Part 2 on page 8 onwards. (Please ask for an explanation of any areas that you do not understand). The following details, together with the Residence Terms in Part 2, form the Agreement which applies to the admission of the Resident named below as a Resident of the Care Home. Resident’s Name: Mr/Mrs/Miss/Ms/Dr/Rev/Other Care Home Name: Date of Admission: / / Resident’s Address: Date of Birth: / / Method of payment: Direct Debit By the time of your admission to the Care Home the Resident and any Third Party Contributor must have a direct debit in place for payment. Name and Address of Resident’s Attorney under a power of attorney (if any) or Resident’s Representative: Name: Address: Interest is charged on late payments at the rate of 4% above HSBC Bank’s base rate from time to time. Post Code: Telephone No: Email Address: Residential Fees (gross weekly) £ Liability for funding/sources (weekly) for Residential Fees Resident £ Third Party Liability £ OR Authority Funding £ (including any contributions to Authority Funding ) Type of PoA: Continuing: Welfare: Combined: Please note that a copy of your PoA may be requested by us. Name and Address of Guarantor:
