Application Instructions for INDEPENDENT LIVING ResidentsPlease complete the following pages entitled:

1. Application for Admission to Colonial Lodge Community

2. Financial Statement and Responsibility

3. Independent Resident Information

Application Instructions for PERSONAL CARE ResidentsPlease complete the following pages entitled:

1. Application for Admission to Colonial Lodge Community

2. Financial Statement and Responsibility

3. The 2-page document: Adult Residencial Licensing – Documentation of Medical

Evaluation (DME)

Faithful Living Community 2015 N. Reading Rd., Denver, PA 17517 (717) 336.5501 1 (800) 406.CARE Fax: (717) 336.3229www.Faithfuliving.com

Application for Admission to Faithful Living Senior CommunityApplication is for: o Independent Living o Personal Care

Applicants Name: _______________________________________________________ Birth Date: _________

_______________________________________________

Street: ___________________________________________________________________________________

City: __________________________________________State: _________________ Zip: _______________

Telephone Numbers

Home Phone: ___________________________________Cell Phone: ________________________________

Work Phone: ___________________________________

Gender: o M o F Eye Color __________________ Hair Color __________________

Are you a Veteran? o Y o N Marital Status: o Single o Married o Divorced o Wid-

owed

Spouse’s Name: _________________________________

Financially Responsible Party

Name: _________________________________________Relationship: _______________________________

Street: ___________________________________________________________________________________

City: __________________________________________State: _________________ Zip: _______________

Telephone Numbers:

Home Phone: ___________________________________Cell Phone: ________________________________

Work Phone: ___________________________________

Insurance Information

Medicare # _____________________________________Part A & B Effective Date _____________________

Social Security # _________________________________Supplemental Insurance ______________________

PACE # ________________________________________PACE Effective Date: ________________________

Medicare Part D Info: _______________________________________________________________________

How did you learn about Faithful Living Senior Community? _______________________________________

Faithful Living Community 2015 N. Reading Rd., Denver, PA 17517 (717) 336.5501 1 (800) 406.CARE Fax: (717) 336.3229www.Faithfuliving.com

Financial Statement and Responsibility Although the information below is an optional disclosure of personal finances, Faithful Living Senior Community does require a guarantee of monthly payments and other services provided for the resident.

Name of Resident: ______________________________________________________

Faithful Living Community 2015 N. Reading Rd., Denver, PA 17517 (717) 336.5501 1 (800) 406.CARE Fax: (717) 336.3229www.Faithfuliving.com

Monthly Income:

Social Security: $ _______________per month

Pension: $ _______________per month

Dividends: $ _______________per month

Interest/Annuities: $ _______________per month

Rental/Mortgage Income: $ _______________per month

Trust Income: $ _______________per month

Other Income $ _______________per month

Total Regular Monthly Income: $ _______________per month

List of Capital Assets:

Cash (savings and checking): $ _______________

Stocks & Bonds: $ _______________

Home Equity: $ _______________

Other Real Estate: $ _______________

Automobile: $ _______________

Life Insurance: $ _______________

Total Assets: $ _______________

List of Liabilities:

Mortgage Payment: $ _______________per month

Notes Payable/Endorsed: $ _______________per month

Personal Debts: $ _______________per month

Total Liabilities: $ ____________ per month

I guarantee that any financial obligations to Faithful Living will be met.

Signature: _________________________________________________ Date: __________________________

Independent Resident Information

Name of Resident:

Room #:

Birth Date:

Social Security #:

Phone # :

Hospital Preference:

Hospital Phone #:

Date of Admission:

Pertinent Medical Information:

Emergency Contact 1:

Relationship:

Phone # 1:

Phone # 2:

2nd Emergency Contact:

Relationship:

Phone # 1:

Phone # 2:

Signature: _________________________________________________ Date: __________________________

Faithful Living Community 2015 N. Reading Rd., Denver, PA 17517 (717) 336.5501 1 (800) 406.CARE Fax: (717) 336.3229www.Faithfuliving.com

None

Td/Tdap Date: In�uenza Date:

Evaluation Information