Victorian Heights Printable Admission Form

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