APPLICATION. Name (print) Last First M.I. Current Address. Cell ( ) - Telephone ( ) - . Permanent Address (if different from above)

Transcription

1 APPLICATION This application must be completed and signed before an applicant may move in. All items must be completed and all information requested must be provided. When a couple applies, each individual must complete a separate application. The undersigned hereby applies for residency at Westchester Center for Independent & Assisted Living and, if accepted, agrees to abide by all current and future community policies and procedures. Name (print) Last First M.I. Current Address Street City State Zip Telephone ( ) - Cell ( ) - Permanent Address (if different from above) SSN: Place of Birth Date of Birth / /19 US Citizen? o Yes o No Primary Language: o English o Other Gender: o Female o Male Marital Status: o Single o Married o Widowed o Divorced Race Religion 1

2 How did you hear of Westchester Center? Have you ever lived in a retirement community? o Yes o No If Yes, please provide the name, address and reason for leaving: Name of Community Address Reason for Leaving RESIDENCY PREFERENCES Apartment type desired: o Companion Studio o Couple Studio o Single Studio o Companion Suite o Couple Suite o Other Anticipated Date of Move-In: At the time of this application I can: Walk o Independently o With Assistance Indicate any adaptive equipment used/needed to move about: Shower o Independently o With Assistance 2

3 Dress o Independently o With Assistance Eat o Independently o With Assistance Take medications o Independently o With Assistance Manage my own personal hygiene (using the bathroom, incontinence, laundry, etc.) o Independently o With Assistance Manage my own diet (make appropriate food choices) o Yes o No Physically move to an exit during an emergency/evacuation o Yes o No Do you require any special assistance in any other area? o Yes o No Do you use oxygen? o Yes o No If yes, do you manage your oxygen-handling on your own? o Yes o No Do you suffer from incontinence? o Yes o No 3

4 Are you now, or have you ever, been treated for or diagnosed with any psychiatric disorder? o Yes o No If yes, please explain: Do you have any condition that would impair your own personal safety, health or well-being, or the safety, health or well-being of others, by living in an independent setting? o Yes o No Please list all medications that you are currently taking. Include any over the counter medications such as Tylenol, Advil, Ibuprofen, Sinus/Cold medications, Sleep Aids, etc. Medication Dose Date Reason EMERGENCY CONTACT INFORMATION Please list the name(s) and telephone number(s) of nearest relative or legally authorized party to call in case of emergency: 1. Name Relation Address Telephone: Home ( ) - Cell ( ) - Power of Attorney: o Yes o No 4

5 2. Name Relation Address Telephone: Home ( ) - Cell ( ) - Power of Attorney: o Yes o No EMERGENCY SERVICES Funeral Home Name City State Tel. ( ) - BILLING Your Primary Insurance is: Your Secondary Insurance is: Currently receiving SSI Payments? o Yes o No Do you have Long Term Care Insurance? o Yes o No Are you on Medicaid? o Yes o No If a recipient of Medicare/Medicaid Coverage, what is your County of origin? o Westchester County o Other For all other payment sources: Monthly rent invoices should be sent to: Name Relation Tel. ( ) - 5

6 Any Additional information: I certify that the information in this application is full, true and correct. I understand this information will be treated as confidential and will only be used in determining my eligibility to reside at Westchester Center. Signature of Applicant Date For Questions regarding the admission process or to schedule a tour, please refer to our website or feel free to contact us: Upon completing the application in its entirety please submit via: Mail - APPLICATIONS 78 Stratton Street South, Yonkers, NY Fax Scan & - Applications@theWcenter.com 6