WCH Foundation Laklinyeri Beach House Application Form

Contact Details

Name of Person making the application:

Name(Required)

First Last

Email(Required)

Mobile(Required)

Work Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Language spoken at home:

Interpreter required?

Yes

No

Do you have Ambulance cover?

Yes

No

PEOPLE INTENDING TO STAY

Please provide FULL NAMES of each person (maximum 11) intending to stay and their relationship to the client/child:

ADULTS

Adult 1

Relationship

Adult 2

Relationship

Adult 3

Relationship

Adult 4

Relationship

Adult 4

Relationship

CHILDREN:

Child 1

Relationship

Gender

Age

Child 2

Relationship

Gender

Age

Child 3

Relationship

Gender

Age

Child 4

Relationship

Gender

Age

Child 5

Relationship

Gender

Age

Child 6

Relationship

Gender

Age

Will you be staying:(Required)

With a client/child under the care of the WCHN Palliative Care team

With a WCH client experiencing medical complexity that would make other holiday options difficult

As a bereaved family

Date of death

In either circumstance, please complete the Client/Child’s details below:

Full Name

Relationship to Applicant:

PREFERRED DATE OF STAY

Please note that all bookings will be a maximum 6 nights / 7 days and will commence on a Friday and conclude the following Thursday. Should you be unable to utilise the whole week, your booking will still need to fall within the Friday to Thursday period. e.g. if you arrive on a Monday, your departure date will still be the Thursday following.

Please indicate your preferred dates of stay including any special circumstances to be considered (ie extended family to attend from interstate or overseas).

CARE INFORMATION

Medical Conditions and Disabilities (please list details of all known medical conditions or disabilities)

Have you stayed at the WCH Foundation Beach House before; or any other charitable accommodation? If yes, please advise date and where accommodation was provided.

Any other comments you’d like to make in support of your application?

Date(Required)

Comments

This field is for validation purposes and should be left unchanged.

Contact Details

PEOPLE INTENDING TO STAY

ADULTS

CHILDREN:

In either circumstance, please complete the Client/Child’s details below:

PREFERRED DATE OF STAY

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