Application form | Havelock Housing

PLEASE NOTE: This form is for disability accommodation or accommodation at Havelock House.

Full Name *

Date of Birth *

Can you provide a brief description of your current situation, and why you are applying for housing?

What country were you born in?

Required for statistical purposes only

Current Address

Country

City

State

Zip code

Contact Number *

Are you of Aboriginal or Torres Strait islander Descent?

Yes - Both

Yes - Aboriginal

Yes - Torres Strait Islander

Required for statistical purposes only

Are you a person living with a disability?

Yes

If yes, please provide a brief description of any accessibility requirements, including wheelchair access, large print, interpreters and any other accessibility requirement.

If you have NDIS funding, please attach a copy of your current plan

For purposes of Disability Housing only. Note that details of your plan may be provided to support providers for matching purposes

Who is your next of kin/legal guardian?

Address of your next of kin/legal guardian

Apt, suite, etc.

Country

City

State

Zip code

Phone number for next of kin/guardian

Please provide a copy of your current Centrelink statement or your payslips for the last six weeks

Please provide copies of your bank statements from the last three months

Emergency Evacuation Assessment

Why is this important? Havelock Housing need to make sure that we can evacuate people in the event of a fire or other emergency. You must complete this form so that we can ensure that you can safely evacuate the building. Any information you provide will be treated in confidence and stored in line with the Privacy Act 1988 and the Privacy Principles.

Do you require the emergency evacuations procedures to be provided in an alternative format e.g. BSL, Braille, tape, large print?

Yes

Are you able to read and identify the signs that mark the emergency exits and evacuation routes to the emergency exits?

Yes

Can you clearly hear a fire alarm?

Yes

Can you raise the alarm if you discover a fire?

Yes

Are you able to independently move to the nearest emergency exit for a safe and timely evacuation?

Yes

Can you use stairs without assistance?

Yes

Do you use a wheelchair or other mobility aid?

Yes

If you use a wheelchair are you able to transfer from your wheelchair without assistance?

Yes

Are there any prescription or non-prescription drugs or medications that you use that may impact on your ability to quickly evacuate?

Yes

Is there anything else you we need to know about to ensure you are able to evacuate the building in the event of a fire or other emergency?

Please sign here

Reset Signature

I certify that the information in this form is true and correct.

Legal Guardians please sign here

Reset Signature

I certify that the information I have submitted on behalf of the applicant is true and correct.