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Boscombe Rotary & Inner Wheel
Housing Association
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Application Form - We value your privacy and the information you submit will be held in a secure location and not shared with any third parties
First name
*
Last name
*
Address
*
Date of Birth
*
Day
Month
Year
Phone
*
Email
*
Family/Friend contact address and details
*
Your Doctors name and surgery details
*
Your mobility, please tick boxes if they apply
Yes I do you have a care package in place
Yes I require help to get dressed and undressed
Yes I can manage stairs
Yes I do require a walking aid
I do not require any assistance
Submit
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