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Application form for Help or Advice from Isle of Wight Council Adult & Community Services

Isle of Wight Council

	Application form for Help or Advice from Isle of Wight Council Adult & Community Services
	Please complete the form giving as much information about the person in need of help as possible. All information provided will remain confidential. All fields marked with a * are required entries

Is this application for you or another person

for me

another person

(only applicable if you answered Another Person in Question 1)

Is that person aware you are asking for help on their behalf?

Yes

Details of the person in need of help

Forename

Surname

Date of Birth

Marital Status

Single

Married

Divorced

Separated

Widowed

Other (Please Specify)

Religion

Building/house name/number

Street address

Town name

County

Postcode

Contact Telephone Number
(include area code)

Email address

Living alone

Yes

Has help or advice has been received previously?

Yes

If 'yes' please give the following details:

	Please tell us what the service was
	Approximately when the service was last received
	Service email address
	Service telephone number

This section is optional but in order to provide a fair and equal service it will help us if you complete it (please click the appropriate boxes)

To help us to identify how to provide the correct service, please complete the following section.

	Any other information

	Your Contact Details
	Please give your contact details if applying on behalf of another person:

	Forename
	Surname

Building/house name/number

Street address

Town name

County

Postcode

Telephone number
(include area code)

Email address

Relationship to the client

Carer

Relative

Other

If you have selected 'Other' above, please briefly explain

	Declaration
	I hereby confirm that the details given in this form are true and correct to the best of my knowledge. Signed ............................................................................... Name................................................................................. Date...................................................................................

Data Protection Act 1998

This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request.

The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest.

Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law.

Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box

To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 07/03/2013