Arbutus Park Manor Application for Admission

Application for: Personal Care Skilled Care Crossraods (Dementai Unit) Short Term Rehab
Last Name	First Name M.I.
Birth Date
Present Address
City	State Zip
Marital Status	Single Married Widowed Divorced
Spouse's Name	(even if deceased)
Birthplace	City State
Occupation	(past or present)
Children	Name Address Phone
Child#1
Child#2
Child#3
Child#4
Social Security #		Medicare No.
Health Insurance		ID No.
	Group No.
Supplemental Ins.		ID No.
	Group No.
PACE No.
Personal Physician	Name:	Phone:
	Address:
Hospital Preference
Durable Power of Attorney	Name: Phone:
	Address:
Financial Power of Attorney	Name: Phone:
	Address:
FINANCIAL INFORMATION
Monthly Income	Social Security	Pension
	Trusts	Other
Assets	Real Estate Address
Vehicles	Year, Make, Model Value
Bank Accounts	Name Account Type Balance
#1
#2
#3
Insurance	Name Face Value Premium


Long Term Care Insurance	Name Face Value Premium

Other Assets (Please Describe)
Liabilities (Please Describe)
Have you made a gift or transferred without full and fair consideration on assets or personal property/real estate in the past year? (Please Explain)
Are you or your spouse a veteran? Yes No Do you recieve benefits now? Yes No
Service Branch Dates Served
Funeral Home Phone No.
Address Irrevocable Burial Fund? Yes No
Cemetary Name Location
Church Affiliation Pastor
Address Phone
Do you have a Living Will? Yes No
I understand that Arbutus Park Manor Retirement Community retains the right to accept or reject any application consistent with the law. I certify that all of the information submitted on this application is true and correct, and I understand the submission of false information may constitute grounds for rejection of this application or my discharge after admission. By indicating my email address below, I thereby execute this document.
Date Current Email Confirm Email Address