Resident Application - Catholic Care Center

X/Twitter

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

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:(Required)

Last Name:(Required)

Date:

Email

Last Permanent Address(Required)

Street Address City State ZIP Code

Phone:(Required)

Cell:

Past/ Present Occupation:

Date Of Birth:

Birth Place:

Location Preference(Required)

Wichita

Mulvane

Martial Status:

Spouse's Name:

Name of deceased spouse:

Religion

Church Affiliation:

Pastor:

Referral Source

Type of Accommodation Desired

Veteran

Yes

No

Branch of Military Service

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.)

Row Start

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:

Column Break

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:

Row End

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 held in checking, savings, and other immediately accessible assets(Required)

Assets held in real estate, stocks, bonds, investments, and non-liquid assets(Required)

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

Total(Required)

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

Total(Required)

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

Total(Required)

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(Required)

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

Search Our Site

Application For Residency

Children

Other Close Relatives or Friends

Responsible Party

General Preferences

Insurance Information

Financial Data

Still there?