Application Form for Residence

This form is an application for registration as an Applicant for Residence in a single or double flat at Abbot's Hospital.

Please read the Application Process and Residence Requirements notes, BEFORE completing the Application Form below.

    Application for Residence Form

    Your Contact Information

    About You

    Income (Yearly or Weekly), Savings and Expenses - please also state if none.

    Two References

    Please give details of two people (not relatives) including your current landlord, if you have one.



    Next Of Kin Contacts

    Please give details of your Next Of Kin Contacts.


    CONTACT 2 (If available)

    Supporting Information


    I declare that the information that I have given in this application is true and I understand that any failure to disclose information, or any attempt to mislead the Hospital during the application process, including the interview and the medical examination, will invalidate my application and may lead to any appointment as a resident being set aside without notice.

    It must be understood that, if I am appointed, I shall occupy as an Alms-house resident under licence in accordance with Charity Law and as a beneficiary of the Charity. I will not be a tenant. Neither the resident(s) nor any relation or guest of his/hers/theirs will be a tenant of the Charity or have any legal interest in his/her/their Alms-house.

    Any regular sum I pay will be a maintenance contribution and not rent.

    I am willing to live quietly, without disturbing my neighbours.

    I agree that if I become unable to care for myself on a permanent basis I shall, if asked to, find and
    move to alternative accommodation.

    Data Protection Statement:

    Abbot’s Hospital is responsible for ensuring that applicants are suitably qualified and may therefore have to investigate applicant’s personal circumstances. The personal data supplied on this form, and other information relating to your application or your care management, will be held on file. Some details may have to be checked or exchanged with other organisations, but none will be disclosed for any inappropriate purpose. You will have access to your personal information on request. All applicants need to understand that data will be kept on file and that, when signing this form, you are signing to agree, explicitly, that Abbot’s Hospital can keep your data for the purposes of administration and management. Your data will be removed when you cease to be an ‘applicant’ for one reason or another or when you leave Abbot’s Hospital if you become a resident if your application is successful. Your data will be kept securely, and it will be kept for no longer than is reasonably required.


    Important: Please remember to also complete the Medical Authority Form which forms part of your Residence Application.