Lifeline Services Request Form
Isle of Wight Council IWC logo
Lifeline Services Request Form
Your Details
Title
* Forename
Middle name/Initials
* Surname
* Building/house name/number
* Street address
* Town name
County
* Postcode
Tel number
(include area code)
Email address
Fax
Recipient's Details
* Are the recipient's details the same as those previously given on page 1?
*If No, please provide the following information about the intended recipient:
Title
Forename
Middle name/Initials
Surname
Building/house name/number
Street address
Town name
County
Postcode
Tel number
(include area code)
Email address
Fax
Service Required
* Please indicate the service you require:

(E) Require a New/Replacement Pendant or Neckcord*

*Please provide us with further details about your requirement in the 'Additional Comments' box below.
Call Back Preference
Please Note: If you have selected option B, C or D above, a call back facility will be put into operation following the receipt of this e-Form to enable us to make an appointment to either demonstrate, install or withdrawl the Lifeline equipment.
* Please indicate a preferred time of day for our Lifeline staff to call you back:  Morning - between 8:30 & 10am
 Morning - between 10am & 12noon
 Afternoon - between 12noon & 2pm
 Afternoon - between 2pm & 4pm
 Afternoon - between 4pm & 6pm
 Evening
* Please confirm the NAME of the person we will need to speak to (as per either 'Your Details' or 'Recipient's Details' above):

* Please confirm the TELEPHONE NUMBER of the person named above:



Your Feedback
Please take a moment to tell us how you first heard about this service:
Additional Information
Please use this space to enter any further comments or specific requirements:
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