Registered Charity 803103
APPLICATION FOR PPP AID CALL
The Tracy Trust provides a PPP AID CALL alarm free of charge to members where a medical condition renders it advisable. (Conditions such as being bed/wheelchair bound, experiencing difficulty / unsteadiness when walking, being unable to leave home without assistance, or after a serious illness.)
We require a written recommendation from a qualified Medical Practitioner.
Please complete your details below and then pass this page of the form to your GP.
Full Name: ………………………………………………….……………………………
Address: ……...............................……………………………………………………..
……………………………………………… Postcode: SL2 ……...………………
Tel. No: ………………………… email: ……………………………………………..
Signed: ……………………………………………... Date: ……………………….…
Signature of Medical Practitioner …………………………………………………….…
Reason for Recommendation: ……………………………………………………….….
……………………………………………………………………………………………....
Next of kin / Close relative.
The cost of the Aid Call equipment and service are undertaken by The Tracy Trust.
Should the equipment no longer be needed, e.g. should the recipient move away from Hedgerley, it must be returned to the Treasurer who will forward it to the Aid Call company.
We require a signature from the next of kin / close relative that this will be done. Failure to return the equipment will incur a cost of at least £100, which is the current charge by the company for non-returned equipment.
Signature of guarantor
I agree to the return of the Aid Call equipment loaned to
………………………………………………………………………………………….
Date: ………………………………………………………….
Relationship to recipient:
…………………………………………………………………………………………….
Contact details:
…………………………………………………………………………………………….
……………………………………………………………………………………………
Phone number:
………………………………………………………………
Please return these two completed forms to the Treasurer: - Rainer Struck, 9 Hedgerley Hill, Hedgerley, SL2 3RJ.
Tel: 01753 646883
We require a written recommendation from a qualified Medical Practitioner.
Please complete your details below and then pass this page of the form to your GP.
Full Name: ………………………………………………….……………………………
Address: ……...............................……………………………………………………..
……………………………………………… Postcode: SL2 ……...………………
Tel. No: ………………………… email: ……………………………………………..
Signed: ……………………………………………... Date: ……………………….…
Signature of Medical Practitioner …………………………………………………….…
Reason for Recommendation: ……………………………………………………….….
……………………………………………………………………………………………....
Next of kin / Close relative.
The cost of the Aid Call equipment and service are undertaken by The Tracy Trust.
Should the equipment no longer be needed, e.g. should the recipient move away from Hedgerley, it must be returned to the Treasurer who will forward it to the Aid Call company.
We require a signature from the next of kin / close relative that this will be done. Failure to return the equipment will incur a cost of at least £100, which is the current charge by the company for non-returned equipment.
Signature of guarantor
I agree to the return of the Aid Call equipment loaned to
………………………………………………………………………………………….
Date: ………………………………………………………….
Relationship to recipient:
…………………………………………………………………………………………….
Contact details:
…………………………………………………………………………………………….
……………………………………………………………………………………………
Phone number:
………………………………………………………………
Please return these two completed forms to the Treasurer: - Rainer Struck, 9 Hedgerley Hill, Hedgerley, SL2 3RJ.
Tel: 01753 646883