Ryedale District Council

 

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Apply for a Contact Ryedale Lifeline

For full details about the Contact Ryedale Lifeline service please visit the Contact Ryedale Ryecare Lifeline Service page.

Please have all the information required before you start to complete this form, as it is not possible to save and return to it. You will need your care company details if you have one, contacts details for your Doctor and for the people who will be your emergency responders.

Dwelling details
Address
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Landline telephone number
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A landline must be active, as we are unable to fit a Lifeline without a landline.

Mobile phone number
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Email address
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Key safe number
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We highly recommend that a key safe is fitted to the property.

Key safe location
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Risks (e.g. dogs, oxygen tanks etc)
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I understand the weekly charge is £
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Payment will be collected by quarterly direct debit.

Is your telephone socket close to an electricty socket?

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Do you require an additional pendant? (extra one off cost, please contact us for current price)

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Would you like telecare to be fitted? If so please advise below:

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What other telecare would you like to be fitted?
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If you are unable to nominate any responders, are you willing to pay callout charges for our partner care company to respond (minimum of approx. £36 per call out)?

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Please note: if you cannot provide any nominated responders and are not willing to pay the call out charge, we are unable to supply the Lifeline.

Address for account if different from above
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e.g. If a family member is arranging payment for you.

Resident details (please complete for all occupiers of the property)
Resident 1
Title
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First name
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Last name
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Date of birth
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Medical information
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Allergies
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Mobility
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Your doctor's name
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Name of surgery
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Surgery phone number
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Does someone else live with you
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Title
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First name
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Last name
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Date of birth
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Medical information
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Allergies
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Mobility
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Do you use a care company?
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Name of care company
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Number and timings of visits
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Phone number of care company
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Contact details
Please provide the details of up to four emergency responders (minimum of two required).
Emergency responder 1
Title
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Name
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Address
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Landline telephone number
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Mobile phone number
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Relationship to you
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Keyholder

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Notes
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Emergency responder 2
Title
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Name
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Address
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Landline telephone number
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Mobile phone number
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Relationship to you
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Keyholder

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Notes
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Emergency responder 3
Title
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Name
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Address
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Landline telephone number
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Mobile phone number
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Relationship to you
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Keyholder

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Notes
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Emergency responder 4
Title
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Name
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Address
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Landline telephone number
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Mobile phone number
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Relationship to you
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Keyholder

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Notes
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On receipt of your request, a member of our Community Team will be in touch to arrange installation.
Please click to show you are human(*)
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Contact us


Ryedale District Council
Ryedale House
Old Malton Road
Malton, North Yorkshire
YO17 7HH

Email: Contact the Council

Phone: 01653 600666

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