SAS - Castleknock Community Centre Laurel Lodge Eir Code D15T3PN

Castleknock Community Centre Laurel Lodge Eir Code D15T3PN

Like us on facebook

Home
Room Hire
Classes
Community G
Coffee Shop
- Menu & Price List
Printing
SAS

You can download and print the SAS form directly from here and send back directly to the community centre.
Please be sure to read the attached flyer below for all information.
If you have any further queries please fill in the link at the bottom of the page and we will get back to you in due course.

pobal_seniors_alert_scheme.pdf
File Size:	70 kb
File Type:	pdf

Download File

Seniors Alert Scheme Participant Application Form

* Indicates required field

Title *

First Name *

First

Last

[object Object]

Gender *

Male Female

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Question 1 - Has the participant received equipment under the previous SAS or CSOP Scheme? *

Yes No

Email *

Date of Birth (Participant Must Be Over 65) *

If (YES) To Question 1 Please state the Year & Further details on Prevequipment received to be included in box below

Comment *

SAS ELIGIBILITY ASSESSMENT

Question 2 - Living Arrangements *

Living Alone Living with Another Eligible Person Living Alone for Significant Periods of Time Carer

Question 3 Type of Equipment Sought (One Option Only)

Note, A connection is preferable as wireless modems are not reliable for SAS personal alarms

Question 3 Options *

1 Base & Pendant Landline 2 Pendant Only Landline 3 Base & Pendant GSM 4 Pendant Only GSM

Question 4 - Is Base Unit being supplied from stock *

Yes No

Question 5 Reasons for Seeking this Equipment ( One Option Only) *

1 Fear Of Crime 2 Feel isolated 3 Past Victim Of Crime 4 Peace Of Mind 5 Existing Health Condition 6 Protect Home

Question 6 How Did you Hear About The Scheme? ( One Option Only) *

1 Community/Neighbourhood Watch 2 Community Group/Worker 3 Local Paper/Newsletter 4 Gardai 5 Doctor 6 PHN/Health Centre/HSE 7 Other

Additional Information *

Submit