Please enable JavaScript in your browser to complete this form.Applicant Information – Step 1 of 5Applicant InformationName *FirstLastSocial Security Number: *Date of Birth *Birth Place *Current Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Marital Status *MarriedSingleDivorcedWidowedVeteran of Armed Services *YesNoBranch of ServiceArmyNavyAir ForceMarine CorpsCoast GuardNational GuardOtherYears of ServiceFormer Occupation *Do you own a automobile *YesNoChurch of choiceFuneral home of choiceHospital of choiceNextEmergency ContactPlease list the individual(s) who should be contacted in case of an emergency. If applicable, include the person who holds your Health Care Power of Attorney and/or Financial Power of Attorney.Emergency Contact Name *FirstLastRelationship to Applicant Emergency Contact AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary PhoneCell PhoneIs this Person the Health Care Power of Attorney? *— Select Choice —YesNoIs this Person the Financial Power of Attorney? *— Select Choice —YesNoUpload Power of Attorney Documents (Optional) Drag & Drop Files, Choose Files to Upload Email *Emergency Contact Name (Second) *FirstLastRelationship to ApplicantEmergency Contact Address Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Phone Cell Phone Is this Person the Health Care Power of Attorney? *— Select Choice —YesNoIs this Person the Financial Power of Attorney? *— Select Choice —YesNoUpload Power of Attorney Documents Drag & Drop Files, Choose Files to Upload PreviousNextNeeds and ServicesPlease checks which answer best describes your needs. Housekeeping *No AssistanceAssistance neededPersonal Laundry *No AssistanceAssistance neededShower *No AssistanceAssistance neededWhirlpool Spa *No AssistanceAssistance neededPersonal Grooming *No AssistanceAssistance neededDressing *No AssistanceAssistance neededWalking to/from Meals or Activites *No AssistanceCane/WalkerWheelchairNighttime Checks *Not NecessaryWould AppreciateAssistance to the Bathroom *No AssistanceAssistance neededHearing Aids *Right earLeft earBothCochlear ImplantsNoneDentures *UpperLowerBothNoneVision *GlassesNo GlassesEmergency Awareness – Please Rate *GoodFairPoorMedication Management – Please rate *GoodFairPoor of Health Do I would like staff to help me mange my medication *YesNoMedication management is delegated and supervised by a licensed RN or PharmacistPreviousNextPhysician Name *AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code List all current Medications Last Physician VisitLast Hospital StayHospital Name: **TB SKIN TEST: REQUIRED 90 DAYS PRIOR TO ADDMISSION** Flu Vaccine *YesNoFlu Vaccine is RecommendedDentist NameAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneLast Dentist AppointmentEye Doctor NameFirstLastAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhonePreviousNextPlease list your available financial resources for Assisted Living Care: **Government funding sources are available if you qualify. We can better advise you of options if you provide accruate information. All applications remain confidential** Cash Assets (Approximately) *Home / Property OwnRentEstimated Value (if owned)Employment Income ($/Month)Social Security Income ($/Month)Pension Income ($/Month)Interest Income ($/Month)Other Income ($/Month)Do you have Long Term Care Insurance? *YesNoPolicy Number *Name of the Long-Term Care Insurer *AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWill you be using Family Care as a payer source? *YesNoManaged Care OrganizationLakelandInclusaCare WisconsinName of Medical InsurerPolicy NumberI understand and agree that the foregoing application is not a contract or reservation for Residency. Nothing contained herein is binding on either party until a Residency Agreement has been signed by both parties. I certify that the information which I have provided in this application is true and correct to the best of my knowledge and belief. Acknoawledgment and Electronic Signature *I have read and agree to the statements above , and I certify that the information provided in this application is true and correct to the best of my knowledge and belief.Electronic Signature – Type Your Full Legal Name *By typing your full legal name below, you are electronically signing this residency application. Date Signed *Submit