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​​Registration of Int​erest for Respite Care

*Please complete all fields and submit all sections
Pre-enrolment application will only be processed when all fields are completed and the Intermediate and Long Term Care Household Means Testing (HHMT) has been conducted and remains valid​


Section 1 – Contact Person Information

SECTION 1: CONTACT PERSON (A)

Contact Person (A)

CONTACT PERSON (B) (if there is more than 1 contact person)

Contact Person (B)

Section 2 – Care Recipient Information

APPLICANT’S PARTICULARS (PERSON RECEIVING CARE)

Applicant’s Particulars




Applicant’s living arrangement



Applicant’s mobility status




Applicant’s feeding needs



Applicant’s transfer/toileting needs



Special nursing needs required





Diagnosed with dementia by medical doctor?


Respite care dates

N/A

Section 3 – Service Providers

ELIGIBILITY CRITERIA

Senior Care Centre - Senior requiring care needs supervision or some assistance with daily care activities such as eating or going to toilet during the day (Please indicate preferred senior care centre in Section 4A).

Nursing Home - Senior requiring care must be physically or mentally disabled because of illness, is dependent and requires assistance in activities such as going to toilet or walking, and is unable to be cared for by family at night (Please indicate preferred nursing home in Section 4B).

Section 3A: SENIOR CARE CENTRE

Click here for full list of service providers, contact details, and opening hours.

Section 3B: NURSING HOME

Click here for full list of service providers, contact details, and opening hours.

Section 4 – Declaration

  1. I/We agree to the terms listed of this form and will accept AIC’s decision on this application.
  2. I/We confirm that all the information given in this application is true and accurate to the best of my/our knowledge. I/We have not purposely left out any important fact. I/We have read through and understand all the requirements in this form and agree to be bound by them.
  3. I/We understand that if I/we have been found to have provided any false or inaccurate information in this application, or if I/we no longer meet the eligibility criteria of the service(s) chosen, my/our application will be rejected.
  4. I/We give consent to provide my/our personal information to:
    1. AIC, for the purposes of processing this application, including checking for main applicant’s HHMT (if any);
    2. Third party service providers, for the purpose of registering interest and application for respite services;
    3. AIC and other government agencies, to carry out research, policy formulation, evaluation, data analysis, planning and statistical analysis;
    4. For AIC’s Data Protection Policy, please refer to our website https://www.aic.sg/data-protection-policy
  5. I/We will fully indemnify AIC against any loss, damage, injury and all other cost and expenses, including any legal cost, which may be incurred as a result of any false or inaccurate information given by me/us or my/our failure to comply with my/our obligations.
  6. I/We acknowledge that this registration does not guarantee me/us a place in the centre or nursing home of my/our choice.

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