Senior Living Services Rochester NY

Residency Application

Please review the application carefully and complete all sections.
Select the communities you would like to apply to:

 The Episcopal Church Home (Skilled Nursing – Rochester) The Center for Rehabilitation (Transitional Care - Rochester) River Edge Manor (Independent Living – Rochester) Brentland Woods (Assisted Living - Henrietta) Seabury Woods (Patio Homes - Gates) Seabury Woods (Assisted Living - Gates) Seabury Woods (Memory Care - Gates) Beatrice Place (Senior Apartments - Greece) Valley Manor (Custom Apartment Homes, Assisted Living, Adult Day Program) Pinehurst (Independent Living – Honeoye Falls)

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

Religion:

Place of Birth:

Birth Date:

Social Security #:

Email:

Marital Status:
 Single Married Divorced Widowed Partner

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

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

Relationship:

Emergency Contact #2

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

Relationship:

Power of Attorney:

 Same as emergency contact #1 ?

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

Health Care Proxy:

 Same as emergency contact #1 ?

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

Funeral Home Arrangements:

Funeral Home:

Contact First (if known):

Contact Last (if known):

Address:

City:

State:

Zip:

Phone:

Fax:

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:

Capital Assets:

Cash (checking & saving):

CDs, Money Market, etc:

Stocks and Bonds:

IRAs, Annuities, etc:

House:

Other Real Estate:

Life Insurance:

Trust Fund:

Other Assets:

Total Assets:

Liabilities:

Home Mortgage:

Loan/Installment Payments:

Other Liabilities:

Total Liabilities:

Plans for Disposition of Home and Real Estate:

Trust Fund:
 Revocable 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:

Health Information

Name and Address of Primary Care Physician:

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

Additional Medical Information:

Additional Medical Insurance Information:

Long Term Care Insurance:

Prescription Drug/Medicare Part D Insurance:

I hereby give permission to my physician to provide health care and medical information as applicable.

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

Co-Resident

Is there a co-resident?  Yes No

Please sign this application by typing your name below.
By signing below, you are hereby affirming that all of the above information is correct and truthful to the best of your ability. Your signature below grants your primary care physician permission to provide health care and medical information as applicable.

Applicant/Designated Representative Signature:

Date:

Co-Resident Signature (if applicable)

Co-Resident Signature:

Date:

In making admission decisions, Episcopal SeniorLife Communities does not discriminate on the basis of race, creed, color, national origin, handicap, gender, age, source of payment, marital status, or sexual preference.