Step 1 of 60%Application For ResidencyCatholic 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: First Last Name: First Date: MM slash DD slash YYYY Email Last Permanent Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:Cell:Past/ Present Occupation:Date Of Birth: Month Day YearBirth Place:Martial Status:Select OneNeverMarriedWidowedSeperatedDivorcedSpouse's Name:Name of deceased spouse:Religion:Church Affiliation:Pastor:Referral Source:Types of Accommodation Desired:ChildrenChildren ListNameAddressTelephone Number Add RemoveOther Close Relatives or FriendsChildren ListName / RelationshipAddressTelephone Number Add RemoveResponsible PartyDo you have a durable power of attorney for medical decision? Yes NoDo 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 First Address Street Address City State / Province / Region ZIP / Postal Code Work #:Home #:Cell:Relationship:Alternative/Secondary:Name First Address Street Address City State / Province / Region ZIP / Postal Code Work #:Home #:Cell:Relationship:Responsible Party/Medical:Name First Address Street Address City State / Province / Region ZIP / Postal Code Work #:Home #:Cell:Relationship:Alternative/Secondary:Name First Address Street Address City State / Province / Region ZIP / Postal Code Work #:Home #:Cell:Relationship:General PreferencesPrimary Physician: First Address:Phone No:Alternate/Specialist Physician: First Address:Phone No:Dentist Physician: First Address:Phone No:Ophthamologist Physician: First Address:Phone No:Hospital: First Address:Phone No:Podiatrist: First Address:Phone No:Pharmacy: First Address:Phone No:Mortuary: First Address:Phone No:Insurance InformationSocial Security No:Hospital Stay Dates: MM slash DD slash YYYY To: MM slash DD slash YYYY Medicare A No:Medicare B No:Other Insurance:1) Name & Policy No:2) Name & Policy No:Veteran: Yes NoSpouse: Yes NoChild: Yes NoPolicy No:Financial DataThe information is Strictly ConfidentialAssets: Total Assets....(Including Checking, Savings, Stocks, Bonds, Investments, Real Estate)TotalLiabilities: Total Liabilities....(Including Credit Cards, Mortgage and Loans)TotalMonthly Income: Total Monthly Income....(Including Social Security, Pension, Interest Income and Royalties)TotalI (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 AgreeBy selecting "Agree" you hereby give your consent.Date MM slash DD slash YYYY Second Applicant's Consent I AgreeBy selecting "Agree" you hereby give your consent.Date MM slash DD slash YYYY Guardian or Guarantor's Signature I AgreeBy selecting "Agree" you hereby give your consent.Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
