Apply for Residence - Affordable Frailcare Cape Town-Douglas Murray Home for the Aged

Applicant Criteria for Admission

Frail - requires 24hr nursing or supervision
Receives a monthly pension
Funeral insurance in place
Has a bar-coded identity book/card which has to be handed in at reception
Has designated family member / guardian able to pay Monthly Family Contribution
Accepts that a non-refundable advance board and lodging must be paid on admission

Please check the options that apply to this applicant

You can Save and Resume Later

Please read the "Code of Conduct for Residents" and confirm that you have read the rules

All residents must abide by the rules of the institution

Strictly no smoking in the home (smoking is only allowed in designated outside areas)
No alcohol or drugs are allowed on the premises
No dangerous weapons or guns are allowed on the premises
No resident is allowed to leave the premises without permission from the Sister-in-Charge
Strict adherence to meal times is requested
Residents must be quiet and respectful during meal times
All residents' clothing must be marked, and be machine and tumble drier friendly
Valuables must be handed in at the office for safe-keeping (management is not responsible for losses if residents do not abide by rules)
All mobile phones, TVs and radios must be declared
Residents' TVs, radios, clothing, etc will be checked for cockroaches on an ongoing basis
TVs and radios in bedrooms must be switched off at 10pm
Strict adherence to visiting times is requested (permission will be granted in special cases)
No visitor is allowed in the rooms or wards without permission from staff
All grievances to be channeled via correct procedure, i.e. Sister-in Charge, CEO, Board
Medication will only be administered by trained staff
Residents are no allowed in the kitchen or laundry areas
Only Doctor prescribed food, special diets and allergies will be considered and catered for
No food is allowed in rooms, unless stored in sealed containers
Food requirements must be declared on admission
Respectful behaviour is required at all times to staff and other residents
All clothing brought in after admission must first be recorded in the Kit Book by the Sister-in-Charge

Disciplinary Measures

Serious misconduct will be referred to the Board and a final written notice will be given
All other rules broken will be dealt with by the CEO

Please tick to confirm you have read the above "Code of Conduct for Residents"

Yes, I have read the Code of Conduct

You can Save and Resume Later

First Name

Email

Please select the relevant option

I am applying for myself
I am applying on behalf of someone

Last Name

Phone

You can Save and Resume Later

Insurance

Name of Insurer

Policy Number

Is your policy paid up?

Yes
No

Will

Have you made a will?

Yes
No

Name of Executor

Phone of Executor

In the event of death, who will take responsibility for funeral expenses, as well as the outstanding debt owed to the Douglas Murray Home?

Name of person

Phone of person

Important:

Your application will only be finalised after this person has signed with a witness to take responsibility.
For health reasons, the body of the deceased must be removed from the premises by the designated undertakers within 2 hours of death. Should this not occur, the Douglas Murray Home reserves the right to appoint an undertaker for this purpose, the costs of which will be passed on to the person listed above.

You can Save and Resume Later

Pension

Type of Monthly Pension

Where?

Amount

Reference Number

Retirement Annuity

Name of Fund

Amount

Reference Number

Other investments

Name of other investment

Property: Do you...

Own property
Rent property

Amount

Person Responsible for Payment of Account

Name

Phone (mobile number)

Email

Relationship

Phone (work)

Important:

Please note that the family contribution portion of the monthly board and lodging fee must be paid no later than the 7th day of each month
Also note, in the case of death of the resident, the family of the said resident will be held liable for any debt owing to the home for outstanding board and lodging fees. All debt with the home must be settled within two months of the passing of the resident.
Failure to comply with the above will result in the debtor being handed over to the Douglas Murray Home attorneys for collection.

You can Save and Resume Later

Hospital Card Number

Please options that apply to you...

You can take care of yourself
You need assistance with feeding
You need assistance with bathing
You need assistance with dressing

Do you require any medical treatment at present?

Yes
No

Have you suffered from any serious illness?

Yes
No

Do you have any physical difficulties?

Yes
No

Please download and print the Douglas Murray Home medical certificate - this needs to be completed and signed by a qualified Medical Practitioner

You can Save and Resume Later

Undertaking and Agreement by Resident Applicant

If I am admitted to the Douglas Murray home for the Aged, I hereby acknowledge and agree to the following:

To abide by the organisation's household rules and any amendments thereto
to pay my monthly board and lodging fees in advance by the 7th day of each month, the amount of which is calculated in accodance with the Douglas Murray Home tariff structure
Any funds belonging to me and given by myself or on my authoriy to the Executor of my estate, may in the event of my death be used towards settling any debt that I may have incurred with the Douglas Murray Home
The Douglas Murray Home does not accept reposnsibilty for any personal possessions, jewlery, documents, etc brought into the Home by me
Should I decide to leave the Home, I will give one calendar's month notice in writing, or pay the Home one month's board and lodging in lieu of a notice
Should I pass while being a resident at the Home, an administration fee equivalent to one month's full board and lodging becomes payable from my estate
The Home reserves the right and has the sole discretion to transfer me from one room to ward to another. I accept that the Home has the right to implement such transfer if in its sole opinion my health status indicates that it is necessary or desirable
Shoudl the need arise for any emergency medical treatment to me, and my next of kin is not available, the Sister-in-Charge may provide consent to such treatment by a medical professional or hospital
The Home reserves the right to give notice to or even discharge any resident who exhibits violent tendencies or anti-social behaviour, into the care of the designated family member or guardian.

Please download and print the Douglas Murray Boarding and Lodging Agreement - this needs to be brought along to your first meeting

Please upload a copy of the applicants ID:

Click or drag a file to this area to upload.

Please upload a copy of your ID (as you are applying on their behalf):

Click or drag a file to this area to upload.

Please check the following to confirm

The applicant agrees to abide by these rules and regulations governing the Home
The applicant agrees to allow the Home Management to administer my Pension

Applicant's Signature

Clear Signature

Your Signature (on behalf of applicant)

Clear Signature

Dropdown

Multiple Choice

First Choice
Second Choice
Third Choice