Apply for a TimeOut Stay

This form must be completed by the Recipient, or a family member/friend going on the TimeOut Stay
  • 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).
  • (i.e. single story home, wheelchair accessible etc.)
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    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.
  • New Zealand European
    Māori
    Cook Island Māori
    Samoan
    Tongan
    Other Pacific Peoples
    Chinese
    Indian
    Other Asian
    Other European
  • Male
    Female
    Gender diverse/ another gender
Finally, TimeOut recipients tell us their illness has contributed to financial strain. During the time of illness, has your whānau experienced:
  • Yes, I agree to the terms & conditions
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