Application Form Seaside Cottages @ Princess Marina House Rustington, West Sussex BN16 2JG

Print Name (First, Middle Initial, Surname)

…………………………………………………………………………………….

Application Form

Office Only G CASE #

Application Form for Short Welfare Break

“Seacot” House, “Shencot”, "Jesters Court" or "Harlequin House"

Preference 1st to 4th Seacot Shencot Jesters Harlequin Details Of Service Person On Whom Eligibility Is Based Surname: Forenames:

Maiden Name: Date of Birth:

RAF Service Number: Rank: Branch /Trade:

Service Dates From: To:

NHS No:

War Disability Pensioner: Yes No % Disability If Deceased Date of Death:

Service Details Verified Yes No By what means :

Station Currently/Last Based:

Details of Eligible Applicant: (if not detailed above )

Surname: Forenames:

Date of Birth: Relationship to person in section A:

Date of marriage:

NHS No:

Details of other persons accompanying Applicant:

Name: Relationship: Age: (if under 18)

Address of Applicant:

Home Tel:

Postcode: Mobile:

Name of Next of Kin:

Surname: Forename:

Relationship:

Home Tel:

Mobile:

catherine.argentTypewritten TextEmail address

Recommendation Please give a description of the circumstances of the applicant including an indication of need, urgency of stay and preferred dates.

Application for 1 Week Other Please state:

Your Details Surname: Forename:

Address:

Postcode: Tel:

Applicants Name: ..…………………………………………. No of Adults: No of Children: Booking Dates Requested: …………………………… Applicants Requirements: Please return this form to PMH Anticipated arrival time:

N.B. “Seacot” / “Shencot” / “Jesters Court ”/ “Harlequin House” is onlyavailable from 3.00pm on arrival day. State property preference 1st - 4th choiceTravelling by Car Bus Rail

Please indicate any special needs or equipment you may require during your stay

1.Seacot

Ground floorSuperking bed En-suite 1st Floor Master bedroom Double 2nd Bedroom Twin 3rd Bedroom Cabin Bed Bathroom 2.Shencot Ground floor Master bedroom Kingsize bed Ground floor 2nd bedroom Superking bed Ground floor Childrens bunk beds Bathroom (low access shower and separate bath) 1st Floor 3rd Bedroom Kingsize bed Playroom Sofa bed (small double)

3. Jesters Court Master bedroom Queensize bed 2nd bedroom

Zip and Link bed Linked or unzipped to make 2 singles Single bedroom Single bed 4. Harlequin House Master bedroom Queensize bed 2nd bedroom Queensize bed Do you require any equipment ? Travel cot High chair Stair gates Stroller

Electric Bed Overhead hoist Adults Electric Wheelchair Manual Wheelchair

Electric Attendant Assisted Wheelchair Electric Scooter

Daily newspaper Delivered Collect from Reception Weekday Please state which paper:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday Please state which paper: ................................................

This Certificate must be signed in order to process your application Declaration (Delete/complete as necessary):

I declare that the information that I have given on this form is correct to the best of my knowledge.

I agree that the information supplied on this form may be shared with voluntary or charitable organisations and relevant statutory agencies for the purpose of furthering my application for assistance.

I agree that information collected as part of the application process may be retained so that any future applications may be speedily processed, and that data generated may be used for follow up assistance, statistical and research purposes.

Signature Print Name Date

For more information about the RAF Benevolent Fund and its work visit www.rafbf.org

Royal Air Force Benevolent Fund, 67 Portland Place, London, W1B 1AR020 7580 8343

The RAFBF is a registered charity in England and Wales (1081009) and Scotland (SCO38109)

CobseoThe Confederation

of Service Charities

RAFBF Caseworker report 23 Sept.indd 8 23/09/2015 22:23

Surname: Forenames: Date of Birth: Service Dates From To: NHS No: Station CurrentlyLast Based: Surname_2: Forenames_2: Date of Birth_2: Relationship to person in section A: Date of marriage: NHS No_2: NameRow1: RelationshipRow1: Age if under 18Row1: NameRow2: RelationshipRow2: Age if under 18Row2: NameRow3: RelationshipRow3: Age if under 18Row3: NameRow4: RelationshipRow4: Age if under 18Row4: NameRow5: RelationshipRow5: Age if under 18Row5: Home Tel: Mobile: Surname_3: ForenameHome Tel: ForenameMobile: fill_28: Surname_4: AddressRow1: AddressRow2: AddressRow3: Tel: Applicants Name: Booking Dates Requested: Please state which paper: Check Box1: 0: Off2: Off

Check Box2: 0: Off1: Off

Means: Date1: Forename: Check Box5: OffCheck Box6: OffNumber adults: 0: 1:

Check Box9: OffCheck Box12: 0: 0: Off1: Off2: Off3: Off4: Off

3: 0: Off1: Off2: Off3: Off4: Off

4: 0: Off1: Off2: Off3: Off4: Off

5: 0: Off1: Off2: Off3: Off4: Off5: Off

Check Box13: 0: Off1: Off2: Off

Text15: 0: 1: 2:

From: ETA: Office Only G CASE: Maiden Name: RAF Service Number: Rank: Branch Trade: Text7: Check Box10: OffCheck Box11: OffText16: Postcode: Name: Address: Postcode_2: Date: Relationship: Print Name: Signature: Text1: 0: 1: 2: 3:

Text2: