Application for Admission - Golden Good Shepherd Home

Social Security Number:*

Medicare Number:*

Date:*

To The Board of Directors of the Golden Good Shepherd Home:

I, the undersigned, herewith apply for admittance to the Golden Good Shepherd Home and therefore submit the following information which I declare to be true in every particular.

Name:*

First Last

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Home/Cell Phone:*

Date of Birth:*

Place of Birth (City, County, State):*

Age:*

Occupation When Working:*

Kind of Business:*

Citizen of What Country:*

Father's Full Name:*

Mother's Full Name:*

Were you ever in the armed services?*

Yes
No

If yes to the above question, which branch of service?

Highest Level of Education:*

Date of Graduation:*

Marital Status:*

Married
Widowed
Divorced
Single

Name of Spouse:

If deceased, date:*

List the names, addresses and phone numbers of immediate family and relationship:*

Please list: Name Address Cell/Home Phone # Email Relationship

Religious Affiliation:

Name & Address of Church Congregation:

Name of Pastor:

Pastor's Phone Number:

Your general state of health:

Are you able to care for your needs?*

Yes
No

Would you require special attention of any kind?*

Yes
No

If yes, please explain:

Do you use tobacco?*

Yes
No

Do you use alcoholic beverages?*

Yes
No

Name of Physician:*

Name of Dentist:*

Name of Eye Doctor:

Kind of residential services needed or preferred:*

Single
Double

Financial Record:

Total Income per month:

Total Income per year:

Pension per month:

Pension per year:

Social Security per month:

Social Security per year:

Pension source:

Public Aid:

Other Assets:

Life Insurance:

Savings:

Checking:

Real Estate Holdings:

Name and Address of Bank:

If the Applicant Becomes Unable to Manage Their Own Finances, Give Name, Address, Telephone Number, and Signature of the Person Who Will Be Responsible For Making the Regular Payments to the Golden Good Shepherd Home.

Responsible Party:*

First Last

Responsible Party's Address:*

Street Address City State / Province / Region ZIP / Postal Code

Responsible Party's Phone:*

Responsible Party's Email:*

Responsible Party's Relationship:*

I will be responsible for staying current on the above applicant's balance due to Golden Good Shepherd Home. Signed:*

Name of Power of Attorney:*

First Last

Address of Power Attorney:*

Street Address City State / Province / Region ZIP / Postal Code

Phone of Power of Attorney:*

Email of Power of Attorney:*

Relationship to Power of Attorney:*

Name of Guardian:

First Last

Address of Guardian:

Street Address City State / Province / Region ZIP / Postal Code

Phone of Guardian:

Email of Guardian:

Relationship to Guardian:

Have You Ever Been a Resident of Any Other Home?

Name of Home:

Date entered:

Reason for leaving:

Will you notify the Golden Good Shepherd Home if/when you are admitted to another home? (It is important that the applicant keep the Golden Good Shepherd Home aware of nees when any change occurs)

When do you wish to enter the Golden Good Shepherd Home?*

At once
At a later date

If at once, give approximate date:

At a later date:

Name and Address of Funeral Director:

Ambulance Service:

Hospital Preference:*

If, after admitted into the Golden Good Shepherd Home, you should suffer mental ailments, making it expedient to terminate your stay there, do you agree to be transferred to some other suitable institution?*

Yes
No

Do you agree that any misrepresentation or omissions of information called for herein will disqualify you for admittance into the Golden Good Shepherd Home and will be cause for dismissal from it if discovered after your admittance?*

Yes
No

Please provide a copy of Living Will and/or DNR.

Max. file size: 29 MB.

Digital Signature of Applicant*

First Last

Digital Signature of Witness:*

First Last