Apply online for a community alarm (lifeline)

Swansea Council is the data controller for the personal information you provide on this form. Your information will be used to provide you with the service that you have requested and will not be used for any other purpose. We will not share your data with any third parties without your explicit consent unless we are required or permitted to do so by law.

Data protection law describes the legal basis for our processing your data as necessary for the performance of a contract. For further information about how Swansea Council uses your personal data, including your rights as a data subject, please see our corporate privacy notice on our website.
Your details
1. Details of the person who will require the Lifeline
2. Title (optional)
3. First name*
4. Surname*
5. Date of birth*
  DD/MM/YYYY
6. Label
  1. House name (optional)
  2. House number (optional)
  3. Floor number (optional)
  4. Street name*
  5. Area (optional)
  6. City*
  7. Postcode*
7. Do you have remote entry?*
  
  Yes
  
  No
8. If you have remote entry please provide details below:
  1. Key safe number (optional)
  2. Key safe location (optional)
9. Important: Please provide us with a valid email address, even if it belongs to a member of your family, a friend, or preferably your nominated contact (please ask their permission first). We will need to send you further details by email once you have submitted your online application.
10. Email*
11. Telephone*
12. Telephone provider*
13. Mobile (optional)
Do you have someone living with you?*
1. Yes
2. No
Details of any other person living with you
1. Title (optional)
2. First name
3. Surname (optional)
4. Relationship (optional)
Details of your health
1. Please tick if you suffer from any of the following:
  
  Deaf or hard of hearing
  
  Blind / partially sighted
  
  Mobility problems
  
  Speech difficulties
  
  Stroke
  
  Angina
  
  Heart attack
  
  Sepsis
  
  Other
2. If 'Other' please explain:
3. Medical treatment
  1. If you or the person living with you are receiving any medical treatment please enter details below
  2. Medical details (optional)
Details of your doctor
1. Doctor's name*
2. Telephone*
3. Address of surgery*

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Apply online for a community alarm (lifeline)

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