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* 1. Is your care home located in the Auckland Region?

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* 2. Are you a current member of The Therapy Box?

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* 3. What care home are you applying for?

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* 4. What is your monthly activity budget? (numbers only, please don't include a dollar ($) sign)

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* 5. What did your facility score on item 1.3.7 on your last care home audit?

See https://www.health.govt.nz/your-health/certified-providers/aged-care to find your care home audit results

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* 6. Tell us why should your facility be chosen to receive a funded Activity Library Membership

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* 7. If my application is successful, I understand that my facility will be invoiced $25 for 12 activity boxes delivered over 12 months.

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* 8. I am happy to write a letter of support to help The Therapy Box in obtaining funding to help other care homes and to provide activity boxes next year

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* 9. What is your email address?

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* 10. What is your phone number?

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