Victorian Heights Application for Admission
Please print and fill out
I am applying for ___1-Bedroom ___First Available ___Studio
Current Living Situation_________________________________________________
____________________________________________________________________
Personal Information Other Information

Name____________________________
Address__________________________
City_____________State____Zip______
Telephone(___)____________________
Medicare #________________________
Social Security #____________________
Age________ Birthdate_______________
Birthplace__________________________
Religion___________________________
Church____________________________

Special Health, personal assistance or daily activity needs:
_____________________________
_____________________________
_____________________________

Emergency Contact:
Name_________________________
Address_______________________
City/St_________________Zip_____

Family Information Home Phone____________________
Work Phone____________________

Responsible party____________________
Relationship to tenant___________________
Address_____________________________
City/State___________________Zip_______
Home Phone__________________________
Work Phone__________________________
Legal Guardianship ____Yes _____No

Patient Advocate:
Name:________________________________
Address:______________________________
Phone:_______________________________

Court Appointed Conservator:
Name__________________________
Address________________________
Phone__________________________

Power of Attorney:
Name__________________________
Address________________________
Phone__________________________

Additional Family Information:
Name________________________________
Address______________________________
Phone:_______________________________
Relationship:___________________________

Name___________________________
Address_________________________
Phone___________________________
Relationship:______________________
Marital Status:____Married ____Widowed ____Divorced ____Single ____Separated
Spouses Name_______________________
Date of Marriage______________________
Previous Marriage____Yes ____No
Address_______________________
If Deceased, date of death__________
If yes, date of marriage_____________

All of the information provided on this entire form will be kept strictly confidential.
Mail to:
Victorian Heights Assisted Living, 1537 US Highway 2, Crystal Falls, MI 49920