SHORT–TERM ACCOMMODATION
PERSONAL DETAILS FORM
PLEASE PRINT CLEARLY AND USE BLACK PEN
Residents Details
(Family Name)
(First Name) (Middle Name)
Male / Female
Date of Birth
Day / Month / Year
James Cook University
Student Number

Nationality
Religion
Degree / Course
Degree / Course
Vehicle
Type, Make, Model/Year & Colour Registration Number
Contact Details
Permanent Home
Address
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……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
Number, Street, Suburb, City, State, Postcode and Country.
Postal address
(if same as home address -
write ‘as above’)
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Telephone Numbers
(inc. area code)
Resident’s Home
Resident’s Mobile
Email Address
Accommodation Required from ________________________________ to __________________________________
Day and Date Day and Date
Please turn over
Health:
List any medical problems, allergies or recurrent disability of which the staff should be aware.
………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
Dietary Requirements:
List any dietary requirements or allergies of which the staff should be aware.
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Next of Kin
1
st
Contact
Name
Relationship to Resident:
Permanent Home
Address
………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………….
Number & Street, Suburb, City, State, Postcode and Country.
Postal address
(if same write ‘as above’)
……………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………….
Telephone Numbers
(inc. area code)
Home
Work
Mobile
Fax
Email
2
nd
Contact
Name
Relationship to Resident:
Permanent Home
Address
………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………….
Number & Street, Suburb, City, State, Postcode and Country.
Postal address
(if same write ‘as above’)
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
Telephone Numbers
(inc. area code)
Home
Work
Mobile
Fax
Email
Account Payment
Details
…………………………………………………………………………………………………………………………………………….
Name Telephone No:
…………………………………………………………………………………………………………………………………………….
Email Address
MEDICAL DECLARATION
In the event that……………………………………………………………. shall, at any time while he/she is resident at Saints Catholic College,
need medical, nursing, or any other treatment or services (including blood transfusion) for illness or bodily injury before it is reasonably
possible to obtain consent to the provision of such treatment or services, I hereby authorise the officers of Saints Catholic College to
engage such persons as may reasonably be needed in that behalf to provide such treatment or services. I understand that if Saints
Catholic College makes payment in consequence of such engagement, or otherwise incurs expenses connected with the provision of such
treatment or services, it will be my responsibility to repay Saints Catholic College the amount of such payments or expenses.
Name:…………………………………………………………………... Signature: …………………………………………
Relationship to resident:…………………………………………… Date:………………………………………………..
click to sign
signature
click to edit
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