Home

Application for Admission

Please review the application carefully and complete all sections.

Select the communities you would like to apply to:

The Episcopal Church Home
(skilled nursing – Mt. Hope)

River Edge Manor
(independent apartments – Mt. Hope)

Brentland Woods
(enriched housing -Henrietta)

Seabury Woods
(memory care - Gates)

Seabury Woods
(patio homes - Gates)

Seabury Woods
(enriched housing - Gates)

Beatrice Place
(independent apartments - Greece)

I. RESIDENT INFORMATION

Name:

Telephone:

Current Address:

Email:

Marital Status:

Religion:

Birth Date:

Place of Birth:

Social Security #:

United States Citizen:

Yes

Naturalized Citizen: If not born in the USA only:

Yes

Date of Naturalization:

Permanent Residency Visa - If not born in USA only:

Yes

Year Residency Visa Obtained:

*** If you were not born in the USA you will need to provide copies of your permanent visa/naturalization papers or green card. Thank you.

Persons to Notify for Emergencies:

Emergency Contact #1

Name:

Relationship:

Street:
Email:

City / State / Zip:

Telephone #:

Emergency Contact #2

Name:

Relationship:

Street:
Email:

City / State / Zip:

Telephone #:

Power of Attorney (if Applicable) Name, Address & Telephone Number:

Health Care Proxy (if Applicable) Name, Address & Telephone Number:

Funeral Home Arrangements (if Applicable) Name, Address & Telephone Number:

II. FINANCIAL INFORMATION

All applicants must complete this section

REGULAR MONTHLY INCOME:
Social Security
Pension
Interest
Dividends
Mortgage/Rental Income
IRA Income
Trust Income
Other Monthly Income
TOTAL MONTHLY INCOME

LIABILITIES:
Home Mortgage
Loan/Installment Payments
Other Liabilities
TOTAL LIABILITIES

CAPITAL ASSETS:
Cash (checking & savings)
CDs, Money Market, etc...
Stocks and Bonds
IRAs, Annuities, etc...
House*
Other Real Estate*
Life Insurance
Trust Fund*
Other Assets
TOTAL ASSETS

* Plans for Disposition of Home and Real Estate:

Trust Fund: Revocable or Irrevocable: When was Trust Fund Established?

Has there been a transfer of assets including but not limited to real estate in the past 60 months?

Yes

If yes, please explain and note date(s) of transfer(s)::

Does resident have a Durable Power of Attorney?

Yes

Conservatorship/Legal Guardian?

Yes

Pending Status of any of the above?

Yes

If Yes, please explain::

III. HEALTH INFORMATION

Applicants should also complete this section.

Name and Address of Primary Care Physician:

Name:

Telephone Number:

Address:

Medicare Number:

Additional Medical Insurance Information:

Carrier's Name:

Policy #:

Do you have prescription drug insurance or Medicare Pt. D name:

I hereby give permission to my physician (physician's name) to provide health care and medical information as applicable.

Please list any other health care providers including
their name, address and telephone number:

IV. CO-RESIDENT

Is there a co-resident?

Yes

Please sign this application by typing your name below.

Applicant/Designated Representative Signature:

Date:

Co-Resident Signature (If applicable)

Co-Resident Signature:

Date:

Click here to submit this application.