APPLY FOR AGED CARE WAITING LIST PERSONAL DETAILS Aged CareDementia Specific This form must be completed by the applicant or person responsible, and returned with a copy of the following Assessments emailed to info@glengollan.com.au: ACCR (Aged Care Assessment) Permanent Residential Aged Care Request for a Combined Assets & Income Assessment Title: —Please choose an option—MrMrsMsMiss Other: Surname*: Given names*: Your date of birth* (DD-MM-YYYY): Male Female Indeterminate / Intersex / Unspecified Country of birth*: Religion: Languages spoken: Phone: Mobile*: Email*: Address*: Postal address: NEXT OF KIN - PERSON #1 Surname*: First name*: Phone: Mobile*: Email*: Postal address: Relationship: NEXT OF KIN - PERSON #2 Surname: First name: Phone: Mobile: Email: Postal address: Relationship: Where is Applicant presently being cared for? Is Applicant’s Doctor prepared to attend our facility? YesNo Name: Address: Phone: Pension number*: Pension type*: AgedVet Affairs Level of Pension*: FullPartSelf Funded Medicare number*: Expiry* (MM-YYYY): Preferred accommodation*: SingleSharedEither How did you find out about Glengollan?: I wish to apply for my name to be placed on the waiting list at Glengollan Residential Aged Care. I understand that a place will only be made available to me after I have had a further interview with the Glengollan Residential Aged Care.*