Application For Residency

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Application for Residency
I. General Information
Resident Name:
Social Security Number:
Address:
City:
State:
Zip Code:
How long at this address?
years.
Telephone where resident can be reached:
Birth Date:
Birth Place:
Gender
Male
Female
Current or former occupation:
Marital Status :
Married
Single
Widowed
Divorced
Separated
In an emergency, who should we call?
Name
Address
Phone
Relationship:
II. Advance Directives and Power of Attorney
Have you completed a living will or advanced directives
Yes
No
Have you made a decision about DNR (do not resuscitate) orders?
Yes
No
If yes, what have you decided?
Do you have a VA. DNR order form completed and signed by your physician?
Yes
No
Power of Attorney for Health Care
Yes
No
If yes, who?
Relationship
Power of Attorney for Finances
Yes
No
If yes, who?
Relationship
(please provide with copies of all documents on advance directives, DNR and Power of Attorney)
III. Current Living Situation
What type of housing do you live in?
In own home
In a family member's home
Nursing Home

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