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Application For Admission

To be completed by potential resident and/or SDM

ENQUIRER'S CONTACT INFO

Name*

Address*

City*

Province*

Preferred Contact Telephone Number*

Preferred Time or Day to be Contacted*

Email*

POTENTIAL RESIDENT's CONTACT INFO

Name of Potential Resident*

Date of Birth*

Current Address*

Current City/Town*

Prov*

Postal Code*

Telephone

Currently residing*
AloneWith spouseWith other caregiverIn a retirement residence/nursing homeOther, please specify:

How did you hear about us? (Please select all that apply)*
WebsiteNewspaperRadio/TV AdWord of MouthOther, please specify:

BACKGROUND INFORMATION

PLEASE TAKE A MOMENT TO COMPLETE THE FOLLOWING INFORMATION INTENDED TO ASSIST US IN ASSESSING ADMISSION ELIGIBILITY FOR OUR HOME.

Does the potential Resident require assistance with completing any of the following tasks independently (Please check the appropriate box).

1. Getting dressed
YesNO

2. Bathing/showering
YesNO

3. Personal grooming/hygiene
YesNO

4. Mobility/Gait/Balance
YesNO

5. Mobility Devices (Please Check)
WheelchairWalkerCaneOther

6. Toileting or continence care
YesNO

7. Other Needs (e.g. glasses, hearing aid, etc. (please briefly describe)

8. Primary language Spoken (list)

Other language Spoken (list)

9. Does Resident smoke?
YesNO

if yes, amount per day

10. Does Resident drink alcohol?
YesNO

If yes; amount and frequency