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APPLICATION FOR ADMISSION TO SENIOR CITIZEN'S APARTMENTS
* Required Fields
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* Full Given Name: |
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*Present Address: |
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*Postal Code |
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*Phone: |
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* Email: |
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Date of Birth: |
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Medicare #: |
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Physician: |
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Specify Present Type of Accomodation: |
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Specify Type of Accomodation Required: |
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List 2 next of kin (# 2 should be alternate if # 1 is unavailable) |
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1.) Name: |
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Relationship: |
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Mailing Address: |
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Postal Code: |
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Home Phone: |
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Business Phone: |
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Email: |
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2.) Name: |
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Relationship: |
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Mailing Address: |
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Postal Code: |
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Home Phone: |
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Business Phone: |
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Email: |
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| Do you wish to be placed on: |
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Active waiting list
(accommodation required within one year): |
Active |
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Inactive waiting list
(accommodation not required within one year) : |
In Active |
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I understand that this application does not constitute an agreement on the part of the Dr. V. A. Snow Centre Inc., to provide me with accommodations |
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Date:
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