Status *

MrMrsMissMsMasterDr

Full Name (Applicant Two) *

Gender *

MaleFemale

DOB *

Mobile Number

Landline *

Email Address *

Contact Preference *

MobileLandlineEmail

Disabilities *

NoneASD/AspergersBlind or Partially SightedDeaf or Hard of HearingHoarding TendanciesMental Health Difficulties Other Disability/Medical ConditionSpecific Learning DifficultyUnseen Disability (e.g. Epilepsy)Wheelchair or Mobility Difficulties

Ethnicity *

White BritishWhite irishGypsy/Irish TravellerOther WhiteWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther MixedAsian BritishAsian IndianAsian PakistaniAsian BangladeshiAsian OtherBlack AfricanBlack CaribbeanBlack BritishCaribbean AfricanCaribbean OtherChinese or other Ethnic groupChineseArabOther

Nationality *

UK National (Resident in the UK)UK National (Returning from residence overseas)Czech RepublicEstoniaHungaryLatviaLithuaniaPolandSlovakiaSloveniaBulgariaRomaniaCroatiaIrelandAustriaBelgiumCyprusDenmarkFinlandFranceGermanyGreeceIcelandItalyLitchensteinLuxembourgMaltaNetherlandsNorwayPortugalSpainSwedenSwitzerland

National Insurance Num. *

Employment Status *

Full Time Work (30 hours or more per week)Part Time Work (Less than 30 Hours per week)Government TrainingJob SeekerRetiredNot seeking workFull Time StudentUnable to work because of long term sickness or disabilityChild Under 16

Is anyone in the household pregnant?

N/AYesNo

Any Sight, Hearing or Language Needs?

NoInterpreter NeededLarge FontBrailleBritish Sign Language User

Has anyone in the household served in the Armed Services? *

N/AYesNo

Does anyone in the household use specialist equipment such as a Mobility Scooter, Oxygen, or anything else? Please state all items *

What is the main reason for you leaving your last settled home? *

Does anyone in the household require specialist access? *

NoDisability RequirementsFull Wheelchair AccessWheelchair Access to Essential RoomLevel Access HousingOther Disability Requirements

Is anyone in the household related to a SLH staff member? *

YesNo

Relationship to Applicant 1

PartnerChild in full-time educationOther

Status

MrMrsMissMsMasterDr

Full Name

Gender

MaleFemale

DOB

Employment Status

Full Time Work (30 hours or more per week)Part Time Work (Less than 30 Hours per week)Government TrainingJob SeekerRetiredNot seeking workFull Time StudentUnable to work because of long term sickness or disabilityChild Under 16

Relationship to Applicant 1

PartnerChild in full-time educationOther

Status

MrMrsMissMsMasterDr

Full Name

Gender

MaleFemale

DOB

Employment Status

Full Time Work (30 hours or more per week)Part Time Work (Less than 30 Hours per week)Government TrainingJob SeekerRetiredNot seeking workFull Time StudentUnable to work because of long term sickness or disabilityChild Under 16

Relationship to Applicant 1

PartnerChild in full-time educationOther

Status

MrMrsMissMsMasterDr

Full Name

Gender

MaleFemale

DOB

Employment Status

Full Time Work (30 hours or more per week)Part Time Work (Less than 30 Hours per week)Government TrainingJob SeekerRetiredNot seeking workFull Time StudentUnable to work because of long term sickness or disabilityChild Under 16

Relationship to Applicant 1

PartnerChild in full-time educationOther

Status

MrMrsMissMsMasterDr

Full Name

Gender

MaleFemale

DOB

Employment Status

Full Time Work (30 hours or more per week)Part Time Work (Less than 30 Hours per week)Government TrainingJob SeekerRetiredNot seeking workFull Time StudentUnable to work because of long term sickness or disabilityChild Under 16

Relationship to Applicant 1

PartnerChild in full-time educationOther

Status

MrMrsMissMsMasterDr

Full Name

Gender

MaleFemale

DOB

Employment Status

Full Time Work (30 hours or more per week)Part Time Work (Less than 30 Hours per week)Government TrainingJob SeekerRetiredNot seeking workFull Time StudentUnable to work because of long term sickness or disabilityChild Under 16

Relationship to Applicant 1

PartnerChild in full-time educationOther

Status

MrMrsMissMsMasterDr

Full Name

Gender

MaleFemale

DOB

Employment Status

Full Time Work (30 hours or more per week)Part Time Work (Less than 30 Hours per week)Government TrainingJob SeekerRetiredNot seeking workFull Time StudentUnable to work because of long term sickness or disabilityChild Under 16