Swindon Home Bid

Wednesday, 10-Mar-2010

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Online Application Form

Main Applicant

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Applicant Details

Title:*

Surname:*

First names:*

Gender:*

Date of birth:* (dd/mm/yyyy)

Are you in full time education? yes no

National insurance number:

Are you expecting a baby? yes no

Date when baby is due: (dd/mm/yyyy)

Please provide a copy of your certificate or hospital record confirming pregnancy

Are you registered disabled or in receipt of Disability Living Allowance (DLA) if under 65 and/or Attendance Allowance if over 65? yes no

If YES, please state level and a brief description of the disability

If DLA, what Level?

Disability:

Is anyone in your household receiving additional care such as meals on wheels, homecare, assistance with bathing, medication or respite care? yes no

If YES, please give details of care

Help details:

Key Worker: yes no

Type of keyworker:

Job title:

Swindon Borough Council has a Corporate Equalities Strategy, which outlines our commitment to providing high quality, appropriate services which meets the needs of the local population. We aim to ensure that no one is discriminated against in the way they access or receive our services. As part of that commitment, we are monitoring what we do and would be extremely grateful, if you could complete this part of the questionnaire. The information you provide will be used to improve service delivery and may be shared with other colleagues in the council for the purpose of monitoring our equalities policies and procedures. How would you describe your ethnic origin?

Ethnic origin:*

Do you consider yourself to have a disability? If yes please tick the appropriate box yes no

Dyslexia: yes no

Deaf/hearing impaired: yes no

Blind/partially sighted: yes no

Mental health difficulties: yes no

Wheel Chair User/Mobility Impairment: yes no

Unseen (e.g. Diabetes, Eplilepsy): yes no

Other disability: yes no

If other, please state details:

Address line 1:*

Address line 2:*

Address line 3:

Address line 4:

Postcode:

Date moved in to this address: (dd/mm/yyyy)

Home telephone:

Mobile telephone:

Work telephone:

If you are happy for us to contact you by email, please provide your email address:

Marital status:

Correspondence Address line 1:

Correspondence Address line 2:

Correspondence Address line 3:

Correspondence Address line 4:

Correspondence Address postcode: