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​​​​​​​​​​​​​​Registration of Int​erest for Respite Care

*Please complete all fields and submit all sections.


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 3A).

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 3B).

To facilitate the application, please prepare a copy of the Care Recipient's COVID-19 vaccination information, *medical Report and *chest X-Ray result (*dated no earlier than 6 months from the intended date of admission).

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 and contact details.

Section 4 – Declaration

    Declaration and Agreement
  1. I/We agree to the terms listed of this programme 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 acknowledge that this registration does not guarantee me/us a place in the centre or nursing home of my/our choice. Placement to centre or nursing home will be subjected to vacancy.
  5. I/We acknowledge that this pre-enrolment will be valid till 20 April 2023 upon completion and I/we will need to update my/our status thereafter.
  6. Consent for Collection, Use and Disclosure of Personal Information
  7. I/We understand that the sharing of my/our Personal Information and the Personal Information of any other individual(s) provided in this application form between the Cooperating Parties1 will assist in the evaluation of my/our and/or that individual’s suitability and eligibility for the Services and Schemes2.
  8. If I/we provide any Cooperating Party with any Personal Information belonging to and/or relating to any other individual for the Purposes (as defined below), I/we represent and warrant that I/we am/are authorised to do so and/or have obtained the consent of that individual to provide that Cooperating Party with such Personal Information for the Purposes.
  9. I/We agree that any Cooperating Party may:
    1. collect my/our Personal Information and/or Personal Information of any other individual provided in this application form, from me/us or any of the other Cooperating Parties;
    2. disclose my/our Personal Information and/or that individual’s Personal Information to any of the other Cooperating Parties; and
    3. use my/our Personal Information and/or that individual’s Personal Information,
    regardless of whether my/our Personal Information and/or that individual’s Personal Information relates to matters occurring before, on or after the date of this consent, for the purposes of:
    1. evaluating my/our and/or that individual’s suitability and eligibility for the Services and Schemes at any time;
    2. the administration and provision of Services and Schemes in relation to me/us and/or that individual; and/or
    3. data analysis, evaluation and policy formulation, in which that individual and/or I/we shall not be identified as specific individuals or households (collectively known as the “Purposes”).
  10. I/We agree to fully indemnify and hold harmless AIC and all other Cooperating Parties from and against any and all liabilities, losses, damages, costs and expenses whatsoever (including legal costs on a full indemnity basis) incurred, paid for or suffered by AIC or any of the other Cooperating Parties arising out of or in connection with the collection, use and disclosure of any individual’s Personal Information based on the declarations and consent provided above.
  11. I/We understand and accept that all Personal Information which I/we have provided to AIC (in this application form or otherwise), including Personal Information belonging to any other individual, is subject to AIC’s Data Protection Policy (available at https://www.aic.sg/data-protection-policy). Therefore, in addition to the Purposes set out above, I/we consent and/or confirm that I/we am/are authorised to consent on behalf of that individual, to the collection, use and/or disclosure of all such Personal Information by AIC for the purposes set out in AIC’s Data Protection Policy.
  12. This consent shall be governed by and construed in accordance with the laws of the Republic of Singapore.

1 "Cooperating Parties" means the Government, participating statutory boards, and organisations approved by the Government that are involved in or assisting in the provision and delivery of the Services and Schemes, including AIC. A "Cooperating Party" refers to any one of the abovementioned entities.

2 "Services and Schemes" means social services schemes, financial assistance schemes and insurance schemes, including:

  1. the Schemes;
  2. financial assistance schemes and insurance schemes administered by AIC;
  3. healthcare, aged care, childcare, education, social assistance and counselling services and schemes;
  4. any form of financial assistance such as subsidies, grants, tax reliefs, levy concessions, vouchers or bursaries; and
  5. retirement, savings and insurance schemes operated by the Government, CPFB or their appointed agents (including Medisave and MediShield Life).

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