The TimeOut Team will be on holiday from the 20th of December and be returning in late January.
From all of us at TimeOut, we wish you and your family a happy and safe holidays.
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Apply for a TimeOut Stay
This form must be completed by the Recipient, or a family member/friend going on the TimeOut Stay
First Name*
Last Name*
Email*
Phone Number*
Recipient Name (person who is ill, if different from above)
Recipient Address*
City*
Postcode
Country*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Azores
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic O
Cook Islands
Costa Rica
Cote d` Ivoire (Ivory Coast)
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France (Includes Monaco)
France, Metropolitan
French Guiana
French Polynesia
French Polynesia (Tahiti)
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And Mc Donald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Ireland (Eire)
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Repub
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Madeira Islands
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts And Nevis
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia-Montenegro
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sand
South Korea
Spain
Sri Lanka
St. Christopher and Nevis
St. Helena
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard And Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Isl
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Vietnam
Virgin Islands (U.S.)
Wallis and Furuna Islands
Western Sahara
Western Samoa
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Adults*
1
2
3
4
5
6
7
8
Children*
0
1
2
3
4
5
6
7
8
Availability*
Please enter some date ranges that you would like to have TimeOut Stay. Note we can only make requests within the following 6 week period after application is received, excluding Christmas/January & public holidays as this is when our homeowners are most likely to be renting their property out or using it themselves (school holidays can also be difficult to secure).
Special Requests
(i.e. single story home, wheelchair accessible etc.)
Let us know some locations (or maximum travel time) you would prefer your TimeOut Stay*
Attach proof of terminal diagnosis
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More Information
eg: Hospital or Specialist letter or letter from GP
Can you please answer these extra questions - TimeOut is a Charity and these quick questions help us with funding applications and reporting. Your information remains confidential and only used for these intended purposes.
Which ethnic group/s and iwi does the Recipient belong to? Please tick the boxes that apply.*
New Zealand European
Māori
Cook Island Māori
Samoan
Tongan
Other Pacific Peoples
Chinese
Indian
Other Asian
Other European
Please provide iwi if known
Gender: How does the recipient identify?*
Male
Female
Gender diverse/ another gender
What is the recipient's age?*
0-4
5 -18
19 - 25
26 - 40
41 - 50
51 - 60
61 - 64
65 - 79
80+
Finally, TimeOut recipients tell us their illness has contributed to financial strain. During the time of illness, has your whānau experienced:
a. financial strain*
Yes
No
b. loss of income*
Yes
No
How did you hear about us?*
Terms & Conditions*
Yes, I agree to the terms & conditions
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