Application for Residency

Catholic Care Center, Inc is committed to proving you with quality care and service. In order to accomplish this goal, we need your help in providing the following information. This application will become a part of the "Resident Agreement" and MUST be completed in its entirety. Catholic Care Center, Inc., affords equal treatment and access to its facilities and services for all persons without unlawful discrimination due to race, color, religion, sex, age, national, origin, ancestry, or disability. All Information will be held in confidence.

First Name:

Last Name:

Date:

Email

Last Permanent Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone:

Cell:

Past/ Present Occupation:

Date Of Birth:

Birth Place:

Martial Status:

Spouse's Name:

Name of deceased spouse:

Religion:

Church Affiliation:

Pastor:

Referral Source:

Types of Accommodation Desired:

Children

Children List

Name

Address

Telephone Number

Other Close Relatives or Friends

Children List

Name / Relationship

Address

Telephone Number

Responsible Party

Do you have a durable power of attorney for medical decision?

Yes

No

Do you have a durable power of attorney for financial decision?

Yes

No

(If someone other than you administers your finances and/or obligations, please list this person's name, address, and telephone number. If power of attorney, trust officer, or guardian for financial or medical decisions, please attach copy of legal documents.)

Responsible Party/Financial:

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Work #:

Home #:

Cell:

Relationship:

Alternative/Secondary:

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Work #:

Home #:

Cell:

Relationship:

Responsible Party/Medical:

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Work #:

Home #:

Cell:

Relationship:

Alternative/Secondary:

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Work #:

Home #:

Cell:

Relationship:

General Preferences

Primary Physician:

Address:

Phone No:

Alternate/Specialist Physician:

Address:

Phone No:

Dentist Physician:

Address:

Phone No:

Ophthamologist Physician:

Address:

Phone No:

Hospital:

Address:

Phone No:

Podiatrist:

Address:

Phone No:

Pharmacy:

Address:

Phone No:

Mortuary:

Address:

Phone No:

Insurance Information

Social Security No:

Hospital Stay Dates:

To:

Medicare A No:

Medicare B No:

Other Insurance:

1) Name & Policy No:

2) Name & Policy No:

Veteran:

Yes

No

Spouse:

Yes

No

Child:

Yes

No

Policy No:

Financial Data

The information is Strictly Confidential

Assets: Total Assets....(Including Checking, Savings, Stocks, Bonds, Investments, Real Estate)

Total

Liabilities: Total Liabilities....(Including Credit Cards, Mortgage and Loans)

Total

Monthly Income: Total Monthly Income....(Including Social Security, Pension, Interest Income and Royalties)

Total

I (we) make this application for residence of my (our) own free will and accord. I (we) declare the information provided to the foregoing questions to be true, complete and an accurate financial account to the best of my (our) knowledge as of the date written below. i (we) authorize and request that my (our) attending physician, surgeon or other person having direct, professional knowledge on my (our) physical or mental health (past or present) provide to the staff at the Catholic Care Center any and all information relative here. Any false or misleading information will void the application approval and/or resident agreement.

Applicant's Consent

I Agree

By selecting "Agree" you hereby give your consent.

Date

Second Applicant's Consent

I Agree

By selecting "Agree" you hereby give your consent.

Date

Guardian or Guarantor's Signature

I Agree

By selecting "Agree" you hereby give your consent.

Date

Phone

This field is for validation purposes and should be left unchanged.

Application for Residency