Application

Application for Residence

Location

Choose a location to apply for residence.

Sagepoint Memory Care
Sagepoint Gardens Assisted Living

Date

Applicant's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone Number*

Cell Phone Number*

Email Address*

Date of Birth*

Current Age*

Please enter a number from 18 to 150.

Social Security Number*

Marital Status*

Single
Married
Widower
Widow

Medicare Number

Other Health Insurance Information (name, address, and policy number)

Current Living Arrangements

Primary Care and/or Other Physician names and telephone numbers

Advance Directives

Do you have...*

Power of Attorney
Durable Power of Attorney
Guardian
Living Will
None of the above

Guardian Name

First Last

Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guardian Home Phone Number*

Guardian Work Phone Number*

Family Information

(Please list the names and addresses of your children)

Name*

First Last

Address*

Home Phone*

Work Phone

Name

First Last

Address

Home Phone

Work Phone

Name

First Last

Address

Home Phone

Work Phone

Additional Contacts

Name

First Last

Address

Home Phone

Work Phone

Current Medical Conditions / Diagnoses

Describe your current medical conditions / diagnoses*

Current Medications and Administration Schedule:

Please include the medications, dosage, frequency, route, and *IF PRN, AVG, FREQ. GIVEN

Allergies (Food and/or Medication)

Financial Information

Monthly Income

Social Security #

Retirement

Other Income

We require proof that the resident has available assets that will allow him/her to stay at CCNRC Family of Care (HomePlace) Assisted Living for at least one year. Please provide bank statements showing savings accounts, checking accounts, CDs, stocks, bonds, etc. that will verify this financial ability.

I agree that if I am accepted as a resident of Sagepoint Family of Care (HomePlace) Assisted Living:

I recognize my financial obligation to pay all doctors fees, hospitalization charges, private duty nursing, and medication charges that I may require that are not covered by government or private insurance.
I will pay monthly, in advance, any charges for which I am responsible.

I hereby certify that all the above information and attached statements are accurate and correctly reflect the financial position of the resident.

We require proof that the resident has available assets that will allow him/her to stay at Sagepoint Family of Care (Abbey Manor) Assisted Living for at least one year. Please provide bank statements showing savings accounts, checking accounts, CDs, stocks, bonds, etc. that will verify this financial ability.

I agree that if I am accepted as a resident of Sagepoint Family of Care (Abbey Manor) Assisted Living:

I recognize my financial obligation to pay all doctors fees, hospitalization charges, private duty nursing, and medication charges that I may require that are not covered by government or private insurance
I will pay monthly, in advance, any charges for which I am responsible.

I hereby certify that all the above information and attached statements are accurate and correctly reflect the financial position of the resident.

Application for Residence

Advance Directives

Family Information

Additional Contacts

Current Medical Conditions / Diagnoses

Financial Information

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