subsidyhealthform Please enable JavaScript in your browser to complete this form.Home Owner Health Subsidy Application FormThe following application form is to apply for a Southland Warm Homes Trust health subsidy of $1000. For approval the following criteria must be met, I am the Home owner/occupier, I'm currently outside the current Warmer Kiwi Subsidy criteria. I live in decile 6&7 area (if unsure our team can check for you, just complete this form) and someone in the household has health issues. Well South will receive the application and assess the information to make a decision on the application. The application process can take 2-3 weeks. Once assessed you will receive notification of the outcome.Applicants Name *FirstLastAddress *I'm a home ownerYesNoCell PhoneEmail *Can you please select ethnicity of people living in the house identify as being: *MaoriPacific IslandNZ EuropeanOtherEthnicity (optional add more info)List below individual family names with health issues, please record family relationship with applicant (example...... My daughter Jo Blog has asthma) *Please name all household members, their relationship to the applicant and any health issues.Health IssuesRespiratory Condition (Asthma, Hib, MMR, Whooping cough)Rheumatic FeverArthritisHeart ConditionI have been admitted to hospital for respiratory condition within the last 12 monthsOther health conditionsDo you have any non urgent health concerns you would like support with? (A nurse may contact you to discuss)Do you have a GP / Medical CentreYesNoIf yes who is your current GP / Medical CentreCurrent Main Source of HeatingNoneHeat PumpCoal BurnerWood BurnerMulti fuel burnerPlug in heatersGas Heater (portable)OtherDoes anyone in the house smoke?YesNoOther supporting comment (optional)DeclarationOnce I submit this form (clicking the submit button below), I declare the above information is true and accurate to the best of my knowledge. I understand that if approved I will receive a Southland Warm Homes Trust $1000 subsidy towards my quote provided by Awarua Synergy. The home is “pledged” to be Smokefree: i.e. tobacco and other substances are not smoked by the occupants within the home and that if I acknowledged I do smoke, a referral to stop smoking will be sent. I give access to Well South to access my health records to check over this application.Submit