AGREEMENT

BETWEEN

NATIONAL INSTITUTE FOR THE DEAF

(SHALOM ELDERLY CARE FOR THE DEAF)

AND

…………………………………………

(Applicant)

THE AGREEMENTThe agreement between the abovementioned parties clearly describes the responsibilities each party accepts in terms of services needed and services provided by the service provider. The agreement will remain binding, for as long as the agreement between both parties exists and holds both parties responsible to carry out their responsibilities.

CLIENTThe client refers to (Full names and Surname)

……………………………………………

an elderly resident of Shalom elderly care for the Deaf.

SERVICE PROVIDERThe service provider refers to Shalom elderly care for the Deaf in Worcester, under the supervision and management of the National Institute for the Deaf in Worcester.

.

APPROVAL FOR

ACCEPTANCE & ADMISSION………...... ……. ………………..

Mrs A van den Bergh Mrs H Jordaan

Manager Social Worker

DATE: …………………….

DOCUMENT 1: ADMISSION FORM

FOR INCLUSION IN SHALOM ELDERLY CARE FOR THE DEAF

SURNAME
FULL NAMES
GENDER
ID NUMBER
DATE OF BIRTH
ADDRESS
TELEPHONE NR
FAX NR
E-MAIL ADDRESS
MARITAL STATUS
IF MARRIED, NAME AND ADDRESS OF SPOUSE(S)
PREVIOUS CAREER?
RELIGION
HOME LANGUAGE
DEGREE OF DEAFNESS
  • DEAF
  • HARD OF HEARING
  • HEARING

HEARING LOSS STARTED AT WHAT AGE?
METHOD OF COMMUNICATION
  • SPEECH
  • LIP READING
  • SIGN LANGUAGE

DO YOU MAKE USE OF A HEARING AID?
HEALTH CONDITION
MEDICAL FUND
MEMBERSHIP NUMBER
NAME/TEL/ADDRESS OF YOUR DOCTOR
CAN YOU STILL TAKE CARE OF YOURSELF?
DO YOU NEED HELP WITH BATHING,
SHOWERING, TOILET?
DO YOU NEED HELP WITH EATING, WASHING, GETTING DRESSED?
SPECIAL DIET, (ALLERGIES, DIABETES, HIGH CHOLESTEROL)?
CAN YOU WALK AROUND WITHOUT ANY HELP?
ARE YOU VERY FORGETFUL?
NAME OF FUNERAL SOCIETY
POLICY NUMBER
DO YOU HAVE A WILL?
NAME AND PHONE NUMBER OF EXECUTOR
NAME OF PENSION FUND
WHERE ARE PAYOUTS BEING MADE?
NAME, ADDRESSES AND TEL NUMBERS OF CHILDREN / FAMILY / 1.
2.
REASON(S) WHY YOU WOULD LIKE TO COME AND STAY AT SHALOM ELDERLY CARE FOR THE DEAF

DOCUMENT 2: FINANCES

(DECLARATION OF INCOME AND EXPENSES)

SURNAME
FULL NAMES
ID NUMBER
INCOME
PENSION / SELF / SPOUSE
1. / R / R
2. / R / R
OTHER INCOME RESOURCES
1. / R / R
2. / R / R
3. / R / R
TOTAL / R / R
REAL ESTATE
DO YOU OWN REAL ESTATE?
MARKET VALUE
OUTSTANDING BOND
IN WHOSE NAME IS THE PROPERTY REGISTERED?

DOCUMENT 3:

(SURETY BY NEXT OF KIN)

Details of applicant regarding the admission at Shalom Elderly Care for the Deaf

SURNAME
FULL NAMES

I………………………...... …… ID number ………...... ……………...... …

hereby declare that in my capacity as ……………......

of abovementioned applicant, that is applying to be admitted to Shalom Elderly Care for the Deaf in Worcester, take full responsibility for the monthly charges, if the applicant, for any reason are not able to fulfill the monthly financial obligations. Further I declare I am fully aware of the contents of the Agreement in respects to the admission requirements at Shalom Elderly Care for the Deaf and consider the Agreement between the two parties as valid and binding.

SURNAME
FULL NAMES
ADDRESS
TEL NUMBER (HOUSE)
TEL NUMBER (WORK)
CELLPHONE
E-MAIL

SIGNATURE / NEXT OF KIN: …………………...... ……..

WITNESS: …………………...... …………..DATE: ……...... ………...

DOCUMENT 4: MEDICAL

MEDICAL REPORT ON

FULL NAMES & SURNAME
DETAILS OF MEDICAL DOCTOR
FULL NAMES & SURNAME
PRACTICE NUMBER
TEL NUMBER
ADDRESS
FOR HOW LONG HAVE YOU BEEN TREATING THE PATIENT?
MEDICAL BACKGROUND
MEDICATION NEEDED
TYPE OF MEDICATION / APPLICATION
GENERAL COMMENTS

………………………………...... Stamp with Practice number:

SIGNATURE: MEDICAL PRACTISIONER

…………………..

DATE

DOCUMENT 5: DOCUMENTATION

ID DOCUMENT / Applicant is requested to attach a certified copy of
his / her ID document prior to the application for
admission at Shalom Elderly Care for the Deaf is
considered.
WILL
Do you have a valid will?
Name of institution where the will is being kept, as well as the address and telephone number
FUNERAL POLICY
Do you have a funeral policy?
Name of Institution
Policy number
Value of policy

I HEREBY DECLARE THAT ALL THE INFORMATION

IN THIS AGREEMENT IS TRUE AND CORRECT.

………………………………………….………………...

SIGNATURE OF DATE

APPLICANT / SURETY