Badisa Waiting List

Person completing the application in respect of a family member:

Name and Surname

Email Address

Contact Number

Personal Details:

Title/Titel

Name/Naam

Surname/Van

Name (Spouse/2nd person)

Surname (Spouse/2nd person)

Marital Status/Huwelikstaat

ID Number

ID Number (Spouse/2nd person)

Tel/Cell

Tel/Cell (Spouse/2nd person)

E-mail Address

Email Address (Spouse/2nd person)

I acknowledge that all future communication will be via email. For assistance, please use the " Need Assistance?" option on the menu.

Current Living Address

Area

Type of Existing Accommodation

Income Bracket

Any stress / anxiety attacks / psychiatric treatment in the past or currently?

If above is Yes, please name the condition/s and medication you are using.

Any chronic conditions for which treatment is currently being received?

If above is Yes, please specify.

Impairments/limitations (Walkers, Wheelchairs, etc.)

If above is Yes, please specify.

Any substance dependence, past or present?

If Yes, please name dependency and duration of dependency.

Have you been previously boarded for any medical reasons?

Do you suffer from any Allergies?

If Yes, please name allergies and describe.

Type of accommodation required:

Choose your preferred programme/s (Hold Control (ctrl) in to select multiple programmes))

Frail Care:

Single Room

Room for Couple

Dementia:

Single Room

Assisted Living:

Single Room

Bachelor flat with en-suite and very small kitchenette

Independent:

Life Right - One Bedroom

Life Right - Two Bedroom

Independent Living

Rent - One Bedroom

Rent - Two Bedroom

Residential Accommodation Urgency:

Urgent - required in 30 days

Urgent - required in 12 months

Can wait 2 - 5 years

Long Term Planning: 5 - 10 years plus

Please expand on urgency option chosen.

Send Copy to My Email

Thank you for your submission.

You will receive a copy of your application via email, if you selected the option on your submission,

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