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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*
 Alone With spouse With other caregiver In a retirement residence/nursing home Other, please specify:

How did you hear about us? (Please select all that apply)*
 Website Newspaper Radio/TV Ad Word of Mouth Other, 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
 Yes NO

2. Bathing/showering
 Yes NO

3. Personal grooming/hygiene
 Yes NO

4. Mobility/Gait/Balance
 Yes NO

5. Mobility Devices (Please Check)
 Wheelchair Walker Cane Other

6. Toileting or continence care
 Yes NO

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?
 Yes NO

if yes, amount per day

10. Does Resident drink alcohol?
 Yes NO

If yes; amount and frequency