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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
No
Naturalized Citizen: If not born in the USA only:
Yes
No
 
Date of Naturalization:
 

Permanent Residency Visa - If not born in USA only:

Yes
No
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
No
If yes, please explain and note date(s) of transfer(s)::
Does resident have a Durable Power of Attorney?
Yes
No
Conservatorship/Legal Guardian?
Yes
No
Pending Status of any of the above?
Yes
No
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)

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

IV. CO-RESIDENT
Is there a co-resident?
Yes
No

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.