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Date of Application: ___________________ Unit Preference: q One bedroom suite q First Floor q Two bedroom suite q Second Floor q Two bedroom/den suite q Third Floor
Tenant Name(#1):_________________________________________________
Current Address:_________________________ Telephone: ( )_________
Zip Code:____________ GENERAL INFORMATION: How long have you lived at the
above address?__________________________ Will it be necessary to sell your present home in order to complete necessary financial arrangements for a move to the Highlands? List your living children:
NAME:
ADDRESS:
PHONE: List other close relatives:
NAME:
ADDRESS:
PHONE: References (other than relatives:)
NAME:
ADDRESS:
PHONE:
Lawyer:_________________________________________________________ Will you require special assistance (personal care, housekeeping, etc.) upon residency at the Highlands? If so, explain? Do you have a personal representative/power of attorney/executor named at this time? If yes, please give list: Name Address Phone Health Statement: Do you feel capable of living independently in your suite at The Highlands with the kind of support services provided as described in the occupancy agreement and other literature about The Highlands? State in your own words the condition of your health: Applicant #1: Applicant #2: Describe any chronic diseases (heart, diabetes, kidney, etc.) Have you (either applicant) been hospitalized within the past year? If yes, what was the cause of your hospitalization? List special diet requirements: Can you prepare your own meals? Do you have any physical handicaps? Do you use any special aides such as a cane, walker, wheelchair, etc. Specify: Condition of sight: Hearing problems: Do you have any serious problem remembering times, places, people? State any regular medical treatment you require which you cannot administer yourself: Are you presently under special medical care? If yes, for what? Health and Accident Insurance Policies:
Company Name:
Type of Insurance:
Policy Number: Are you covered by Medicare, Part A? Part B? Do you have Long Term Health Care (Nursing Home) Insurance? If yes, please list company name and policy number?
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