PEVENSEY PLACE ASSOCIATION

Adult Cerebral Palsy Centre / OordvirVolwasseSerebraalgestremdes

FRO: 002-155NPO

Enquiries Mr R Nyathi

Tel: 087095 1128

e-mail:

Dear

RE: APPLICATION FOR ADMISSION

Attached please find an application form as well as an assessment form to be completed regarding admission to Pevensey Place.

The application will only be considered after the receipt of all documents and reports required.

Kind regards,

J F Niemand

Director

Private Bag X313, Underberg, 3257

Telephone Office 087940 3614. Fax:086 657 6161

A Branch of The Natal Cerebral Palsy Association

APPLICATION FOR ADMISSION TO

PEVENSEY PLACE

1.IDENTIFYING PARTICULARS (Applicant)

SURNAME:………………………………………………………………………………………………………………………………………..

NAMES: ……………………………………………………………………………………………………………………………………………

DATE OF BIRTH:…………………………………………………………. SEX:………….………………………………………………..

NATIONALITY…………………………………………………….*ID NO: ………………………………………………………………..

HOME LANGUAGE: ………………………………………….. OTHER SPOKEN:. ………………………………………………...

RELIGION: ………………………………………………………………………………………………………………………………………..

*CERTIFIED COPY OF ID DOCUMENT TO BE ATTACHED

2.FAMILY COMPOSITION / PARTICULARS

2.1NAME OF FATHER …………………………………………………………………………………………………….

ADDRESS: ………………………………………………………………………………………………………………….

TEL. NO. (H) ……………………………………………..(B): ………………………………………………………..

CELL: ………………………………………………………………………………………………………………………..

2.2NAME OF MOTHER: …………………………………………………………………………………………………

ADDRESS: ………………………………………………………………………………………………………………….

TEL. NO. (H) ……………………………………………..(B): ………………………………………………………..

CELL: ………………………………………………………………………………………………………………………..

2.3BROTHERS AND SISTERS:DATE OF BIRTH

………………………………………………….…………………………………………………………..

………………………………………………….………………………………………………………….

………………………………………………..………………………………………………………….

………………………………………………..…………………………………………………………

-1-

3.GUARDIANSHIP

IF THE APPLICANT IS UNDER THE GUARDIANSHIP OF ANY OTHER PERSON THAN THE BIOLOGICAL PARENTS OR IN THE CASE OF A DIVORCE, PLEASE STATE FULL PARTICULARS

NAME OF GUARDIAN: …………………………………………………………………………………………………………

ADDRESS OF GUARDIAN: …………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………

TEL. NO. (H) ……………………………………………….……..(B): ………………………………………………………..

CELL: ……………………………………………………………..…………………………………………………………………..

4.EDUCATIONAL HISTORY OF APPLICANT

4.1HAS THE APPLICANT ATTENDED ANY MAINSTREAM SCHOOLS? IF SO, PLEASE COMPLETE THE FOLLOWING:

NAME OF SCHOOLFROMTO

………………………………………………………………………….………………………………………..

………………………………………………………………………….………………………………………..

………………………………………………………………………….………………………………………..

………………………………………………………………………….………………………………………..

4.2HAS THE APPLICANT ATTENDED ANY SPECIAL SCHOOLS / INSTITUTIONS? IF SO, PLEASE COMPLETE THE FOLLOWING:

NAME OF SCHOOLFROMTO

………………………………………………………………………….………………………………………..

………………………………………………………………………….………………………………………..

………………………………………………………………………….………………………………………..

………………………………………………………………………….………………………………………..

4.3HIGHEST LEVEL OF EDUCATION: ……………………………………………………………………………..

-2-

4.4A CONFIDENTIAL SCHOOL / INSTITUTIONAL REPORT WHERE THE APPLICANT IS AT THE MOMENT MUST BE ATTACHED HERETO. IF THE APPLICANT STAYS AT HOME, GIVE FULL DETAILS.

………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………

4.5HAS THE APPLICANT BEEN DIAGNOSED AS BEING CEREBRAL PALSIED?

………………………………………………………………………………………………………………………………..

4.6GIVE ADETAILED DESCRIPTION OF THE APPLICANT’S DISABILITY:

………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………

5.GENERAL MEDICAL INFORMATION

5.1NAME AND ADDRESS OF MEDICAL DOCTORS WHO HAVE ATTENDED TO THE APPLICANT IN THE LAST TWO YEARS

(1) …………………………………………………………….. TEL NO: ……………………………………………….

(2) …………………………………………………………….. TEL NO: ……………………………………………….

(3) ……………………………………………………………… TEL NO: ………………………………………………

5.2NAME AND ADDRESS OF DENTIST: …………………………………………………………………………..

…………………………………………………………………… TEL NO: ……………………………………………..

5.3NAME AND ADDRESS OF OPTICIAN: ………………………………………………………………………..

…………………………………………………………………… TEL NO: ……………………………………………..

-3-

5.4NAME AND ADDRESS OF ANY OTHER SPECIALISTS: ………………………………………………….

…………………………………………………………………TEL NO: ……………..…………………………………

5.5STATE HOSPITALS OR CLINICS ATTENDED DURING THE LAST TWO YEARS

HOSPITAL ………………………………………. CARD ………………………..NUMBER …………………..

HOSPITAL ………………………………………. CARD ………………………..NUMBER …………………..

HOSPITAL ………………………………………. CARD ………………………..NUMBER …………………..

5.6DOES APPLICANT HAVE HOSPITAL OR CLINIC CARD? ………………………………………………..

5.7DOES APPLICANT BELONG TO MEDICAL AID? PROVIDE DETAILS: …………………………….

………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………….

6.MEDICAL HISTORY OF APPLICANT

6.1WAS BIRTH NORMAL? ……………………………………………………………………………………………..

6.2WHEN DID CHILD FIRST SIT UP? ……………………………………………………………………………….

WALK?...... TALK? ………………………………………………….

COMMENTS: …………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………….

6.3AGE WHEN ABNORMALITY WAS FIRST NOTICED: …………………………………………………….

COMMENTS: …………………………………………………………………………………………………………….

6.4HAS THE APPLICANT BEEN VACCINATED OR IMMUNISED AGAINST THE FOLLOWING:

DIPHTHERIA………………………. AGE ………………….. TYPHOID…………… AGE …………………

WHOOPING COUGH…………..AGE ………………….POLIO…………………. AGE ………………..

BCG……………………..…………….AGE ……………….. MMR …………………. AGE ………………….

-4-

6.5HAS THE APPLICANT EVER SUFFERED FROM:

CHICKEN POX ………………….. AGE …………POLIO ……………………..…AGE ………………………

WHOOPING CHOUGH ………..AGE …………SCARLET FEAVER ………….AGE…………………..

MENINGITIS……………………….AGE …………DIPHTHERIA……..…….…….AGE …………………..

MEASLES ………………………….AGE ………….ENCEPHALITIS……………….AGE……………………

MUMPS …………………………..AGE …………. GERMAN MEASLES…….. AGE…………………….

6.6HAS THE APPLICANT BEEN STERILIZED? …………………………………………………………………

FORM OF STERILIZATION OR CONTRACEPTIONS: HYSTERECTOMY / VASECTOMY /

TUBALIGATION / THE PILL / INJECTION / ANY OTHER METHOD ……………………………….

6.7ANY POSSIBLE ALLERGIES: ………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………….

6.8IN THE CASE OF A HISTORY OF FITS AND OR SEIZURES A NEUROLOGICAL REPORT MUST ACCOMPANY THIS APPLICATION.

6.9IS THERE CONTINUOUS MEDICATION BEING ADMINISTERED? ……………………………….

GIVE DETAILS: ……………………………………………………………………………………………..…………..

…………………..…………………………………………………………………………………………………………….

6.10SUBJECT TO FITS? ………………… IF SO, WHEN DID THEY START? ………………………………..

…………………………………………………………….FREQUENCY ………………………………………………………….

COMMENTS: …………………………………………………………………………………………………………………….

6.11OPERATIONS: STATE ANY MINOR OR MAJOR OPERATIONS, BY WHOM, WHEN AND

WHERE PERFORMED ……………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………

7.FINANCIAL MATTERS

7.1DOES THE APPLICANT RECEIVE A DISABILITY GRANT? ………………………………………………

-5-

IF SO, GIVE THE DATE OF ISSUE AND NUMBER ……………………………………………………….

………………………………………………………………………………………………………………………………..

(CERTIFIED COPY TO BE ATTACHED)

7.2MONTHLY INCOME OF PARENTS:

FATHER / GUARDIAN: ……………………………………………………………………………………………….

MOTHER / GUARDIAN: …………………………………………………………………………………………….

8APPLICATION AND DECLARATION:

I/WE THE UNDERSIGNED ……………………………………………………………………………………………………..

AND / OR ………………………………………………………………………………………………..DO HEREBY APPLY

FOR THE ADMISSION OF ……………………………………………………………………………………………………….

TO PEVENSEY PLACE ASSOCIATION FOR CEREBRAL PALSIED ADULTS. I / WE FURTHER DECLARE THAT ONE, OR BOTH OF US IS THE LEGAL GUARDIAN OF THE APPLICANT AND THAT WE HAVE NOT BEEN DEPRIVED OF THE GUARDIANSHIP OF SUCH APPLICANT.

DATED AT …………………………………THIS …………….DAY OF …………………………………………20……..

…………………………………………………………AS WITNESSES:

PARENT / GUARDIAN

(1) …………………………………………………………..

……………………………………………………………

(NAME IN BLOCK LETTERS)

…………………………………………………………

PARENT / GUARDIAN(2)……………………………………………………………

……………………………………………………………..

(NAME IN BLOCK LETTERS)

NB:PLEASE ATTACH A RECENT PHOTO OF THE CANDIDATE TO THIS DOCUMENTATION.

-6-

PEVENSEY PLACE

ASSESSMENT OF THE DEGREE OF PHYSICAL AND MENTAL

DISABILITY OF AN APPLICANT

Name of Applicant
Date of Birth
Nature of Disability

Please mark with an (X) in the available block, the characteristic under the headings which is most applicable to the applicant.

  1. MOBILITY
  1. Moves independently, with or without appliances
  1. Moves with the aid of a walking stick, walking frame, wheel-chair with partial support or supervision
  1. Moves only when aided by staff
  1. Bedridden and totally dependent upon assistance. Must be transferred from bed/chair/bed.
  1. Comments: ......

......

  1. PERSONAL HYGIENE

2.1Care of hands, face and feet:

  1. Completely independent
  1. Requires supervision
  1. Requires assistance, e.g. nail cutting
  1. Totally dependent
  1. Comments: ......

......

………………………………………………………………………………………………………………………………………………………….

-1-

2.2Oral Care

  1. Completely independent
  1. Requires supervision to care for teeth
  1. Requires assistance with care of teeth
  1. Totally dependent. Requires care with aid of mouth tray.
  1. Comments: ......

......

2.3Bath / Shower

  1. Completely independent
  1. Requires encouragement and supervision
  1. Requires assistance
  1. Dependent - must be bathed
  1. Comments: ......

......

  1. EATING / DRINKING CAPABILITIES
  1. Completely independent
  1. Requires encouragement and supervision
  1. Requires partial assistance e.g. to cut meat, butter bread or must be encouraged to eat
  1. Totally dependent upon assistance
  1. Dependent on tube feeding
  1. Comments: ......

......

………………………………………………………………………………………………………………………………………………………..

-2-

  1. CLOTHING
  1. Dresses / undresses completely independently
  1. Requires supervision for dressing / undressing
  1. Requires assistance to dress / undress e.g. with buttons, zips, shoelaces, etc.
  1. Totally dependent
  1. Comments: ......

......

  1. SIGHT
  1. Sight good or impaired but able to function independently
  1. Sight poor - requires partial assistance
  1. Blind - totally dependent on assistance
  1. Comments: ......

......

  1. HEARING
  1. Hearing good to reasonable to deaf but able to function independently
  1. Hearing poor to deaf. Communicates with difficulty and / or is a disturbance to others
  1. Hearing poor to deaf: a risk to him/herself and others
  1. Comments

......

  1. TREATMENT

7.1Medication:

  1. Uses medicines independently as and when required
  1. As “a” but monthly control necessary. Medicines must be ordered for resident
  1. Medicines must be administered, requiring specialized assistance

-3-

  1. Comments ......

......

7.2Care of Pressure areas:

  1. Nor required
  1. At least 3 times a day
  1. Every 4 hours
  1. Every 2 Hours
  1. Comments
  2. ......

………………………………………………………………………………………………………………………………………………………..

  1. TOILET HABITS
  1. Self-sufficient. Complete control of functions
  1. Self-sufficient, but experiences problems with stress or mild incontinence. Requires encouragementto practice bladder control. Requires supervision with use of toilet.
  1. Periodic accidents with no prior preventative measures
  1. Requires catheter and / or colostomy care
  1. Total urine and fecal incontinence.
  1. Comments
  2. ......

......

  1. THERAPEUTIC ACTIVITIES (e.g. handiwork, exercise, guidance, counselling, socialising, handling of money)
  1. Requires no motivation or support
  1. Requires 15 - 30 minutes support per day
  1. Requires 30 - 60 minutes support per day
  1. Requires support in excess of 60 minutes per day.

-4-

  1. Comments

......

......

  1. MENTAL CONDITION
  1. Memory good - no support required
  1. Failing memory e.g. no recollection of where clothing or articles were placed
  1. Serious loss of memory / confused / antisocial behaviour or aggressive.
  1. Comments
  2. ......

......

10.1Emotional support (Counselling and / or support)

  1. No support required
  1. Requires support 15 - 30 minutes per day
  1. Requires support in excess of 30 minutes per day.
  1. Comments:......

......

10.2Communication capability

  1. Normal communication
  1. At times unable to communicate desires / needs
  1. Total absence of communication
  1. Comments

......

......

…………………………………………………………………………………………………………………………………………………………

-5-

10.3Orientation (In respect of time, place and person)

  1. Normal
  1. At times disorientated
  1. Often disorientated, restless wanders
  1. Continuously disorientated, but does not disturb other residents
  1. Total disorientation. Goes astray / must be attended / disturbs others / apathetic
  1. Comments:

......

......

10.4Comprehension

  1. Good ability to follow simple instructions and to understand motives and situations
  1. Able to follow simple instructions, but poor understanding of motives and situations
  1. Poor ability to follow simple instructions
  1. Unable to follow either simple instructions or understand motives and situations.
  1. Comments:......

......

  1. WORK ABILITY (To be completed in respect of non-aged disabled persons only)
  1. Able to work in sheltered employment / open labour market
  1. Able, after instructions to perform protected work with little supervision
  1. Requires regular supervision to perform protected work
  1. Unable to perform any protected work
  1. Comments:......

......

-6-