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
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