Residential Aged Care Online Application Form

Eldercare Evanston Park resident smiling at the camera.

Thank you for choosing to apply for accommodation with Eldercare.

Once you have successfully finished this application, you will receive an email explaining the next steps in the process.

Please note that completion of this application, and inclusion on the list, does not constitute an offer of placement at an Eldercare facility.

By providing personal details to Eldercare, you are giving us your express consent to use this information to determine the applicant’s suitability for vacancies as they arise.

All personal information submitted to Eldercare will be stored securely and used solely for the purpose of determining applicants’ suitability for accommodation.

Applicant Details

First Name *

Last Name *

Date of Birth

Gender *

Street 1 *

City *

State *

Postcode *

Phone *

Email *

Current Accommodation *

Contact Person Details

First Name *

Last Name *

Relationship to Applicant *

Street 1

City

State

Postcode

Phone

Mobile Phone

Facility Preference

Site Preference 1 *

Site Preference 2

Site Preference 3

How did you hear about us? *

You have the option of continuing this application online by completing the following two sections. To proceed, please click on the Show button below and submit your information.

Alternatively, you can provide this information when a Residential Admissions team member contacts you to discuss your application.

Applicant's Legal Representative

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Enduring Power of Attorney

Power of Attorney Name

Power of Attorney Phone

Advance Care Directive (Enduring Power of Guardianship/Medical Power of attorney)

SACAT Orders in place

Administration

Guardianship

Special Powers

General Information

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Does the applicant have an ACAT approval?

ACAT Approval Effective Date

Pension Type

Pension Number

Has a residential care Assets and Income Assessment been completed?

Does the applicant own a house?

Carer or Close Relative Living in House

Is a Memory Support Unit required?

Reason for AdmissionOptional

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Residential Aged Care Online Application Form

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Applicant Details

Contact Person Details

Facility Preference

Applicant's Legal Representative

General Information

COVID-19

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Residential Aged Care Online Application Form

Your submission is being processed…

Applicant Details

Contact Person Details

Facility Preference

Applicant's Legal Representative

General Information