Call Us Today!
717-285-5443
717-285-5443
Navigation
Home
About Us
Blog
Board of Trustees
Mission, Vision & Core Values
Monthly Community Calendars
Employment
Directory
Video Gallery
Volunteer
Health News Update
Care Services
Skilled Care
Personal Care
Memory Support
Rehab and Therapy Services
Make a Payment
Independent Living
Apartments
Independent Living Cottages
Original Style Villas
Make a Payment
Giving
Commemorative Bricks
Sponsor a Day of Stay
Events
Business Day of Stay Partners
Contact Us
One Campus. All Levels of Living. Apply Today for FREE.
Admission Application
Please submit one application per person.
Please enable JavaScript in your browser to complete this form.
This Application is for:
*
Immediate Need
Future Need: 1-6 months
Future Need: 6-12 months
Future Need: 1+ years
Applying For:
*
Apartments
Cottages
Personal Care
Personal Care Memory Support
Skilled Care
Skilled Care Memory Support
How did you hear about St. Anne's Retirement Community?
Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
Cell Phone
Home Phone
*
Date of Birth
*
Place of Birth
Gender
*
Male
Female
Marital Status
*
Married
Single
Widow
Spouse's Name
Do you have an Advanced Directive/Living Will?
*
Yes
No
Do you have a Durable Power of Attorney (POA) for Health Care?
*
Yes
No
Power of Attorney's Name
Phone
POA's Address
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
POA's Email
*
Type of POA
Financial
Medical
Financial & Medical
Do you have a Will?
*
Yes
No
If yes, who is the Executor?
Family
Children/Significant Other (Please list individuals in the order they should be contacted if unable to reach POA)
Name
*
First
Last
Relationship
*
Work Phone
Cell Phone
*
Address
*
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
#2
Name
First
Last
Relationship
Work Phone
Cell Phone
Address
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
#3
Name
First
Last
Relationship
Work Phone
Cell Phone
Address
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
Care Preference
To Be Admitted From
Residence
Hospital
Rehab Hospital
Health Facility
If Hospital- Name and Unit
List inpatient Stay Dates for Past Year (Hospital, Other Facility, Transitional Care, etc.)
Long Term Care Goal
*
Return Home
Transfer to another Facility/Level of Living
Remain at St. Anne's
Primary Health Insurance (Medicare, Advantage Plan, PPO)
Insurance Company
*
Policy / ID Number
*
Group Number (if applicable)
*
Address
*
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
If Health Insurance is Medicare: Part A Effective Date
If Health Insurance is Medicare: Part B Effective Date
Secondary Health Insurance
Carrier Name
Insured Name
Address
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
Policy/ID #
Group Number (if applicable)
Annual cost for insurance is
Do you have Long Term Insurance?
*
Yes
No
Policy #
*
Daily Personal Care Benefit
*
Daily Skilled Nursing Benefit
*
If Yes, Carrier
Address
*
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Do you have Life Insurance
*
Yes
No
If Yes, Company
Face Value
Cash Value
Beneficiary
Have you applied for Medical Assistance (MA)
*
Yes
No
If Yes, when?
Medical Assistance #
*
Are you a veteran/spouse of a veteran
*
Yes
No
Branch of Service
Do you take prescription medicines
*
Yes
No
What is the average monthly cost?
Do you receive medication from the VA?
*
Yes
No
Do you have a prescription card?
*
Yes
No
What is the type of card?
*
Community Contacts
Community Physician
*
Phone
*
Church Name
Phone
Address
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Funeral Home Preference
Do you have a Burial Trust/Prepaid Funeral?
*
Yes
No
Power of Attorney
Have you, or your Power of Attorney, received financial planning services?
*
Yes
No
If yes, Name(s) of financial planning service employed by you, or your Power of Attorney
Do you, or your Power of Attorney, have an attorney assisting you?
*
Yes
No
If yes, Name of Attorney
Phone
Have you disposed of, or gifted, real estate or personal property within the last 5 years?
*
Yes
No
If Yes, list date and explain:
Please be prepared to supply copies of your latest statement for the assets listed below
Please identify if the asset, liability or monthly income are joint or individual, by selecting individual, joint, or spouse in the corresponding column. If this does not apply, please enter $0 for the amount.
Assets
Total Cash
*
Cash
*
Individual
Spouse
Joint
Total Checking
*
Checking
*
Individual
Spouse
Joint
Total Savings
*
Savings
*
Individual
Spouse
Joint
Total Certificates of Deposit
*
Certificates of Deposit
*
Individual
Spouse
Joint
Individual Retirement Accounts, 401K
*
Individual Retirement Accounts, 401K
*
Individual
Spouse
Joint
Mutual Funds
*
Mutual Funds
*
Individual
Spouse
Joint
Annuitites
*
Annuities
*
Individual
Spouse
Joint
Stocks and Bonds
*
Stocks and Bonds
*
Individual
Spouse
Joint
Real Estate
*
Real Estate
*
Individual
Spouse
Joint
Trust Accounts
*
Trust Accounts
*
Individual
Spouse
Joint
Loans to Others
*
Loans to Others
*
Individual
Spouse
Joint
Total Assets
*
Please add your total amount of assets and place on the line above.
Liabilities
Rent
*
Rent
*
Individual
Spouse
Joint
Credit Card Debt
*
Credit Card Debt
*
Individual
Spouse
Joint
Other Debts
*
Other Debts
*
Individual
Spouse
Joint
Mortgage Balance
*
Mortgage Balance
*
Individual
Spouse
Joint
Total Liabilities
*
Please add your total amount of liabilities and place on the line above.
Monthly Income
Social Security
*
Social Security
*
Individual
Spouse
Joint
Pension
*
Pension
*
Individual
Spouse
Joint
Annuities
*
Annuities
*
Individual
Spouse
Joint
Investment Income
*
Investment Income
*
Individual
Spouse
Joint
Rental Income
*
Rental Income
*
Individual
Spouse
Joint
VA Benefits
*
VA Benefits
*
Individual
Spouse
Joint
Total Monthly Income
*
Please add your total amount of monthly income and place on the line above.
Real Estate Owned
Please provide the locations of each property owned and its value.
#1 Address
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Estimated Value
Mortgage Balance
#2 Address
Address Line 1
Address Line 2
City
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Estimated Value
Mortgage Balance
Other Assets
#1 Asset
Fair Market Value
#2 Asset
Fair Market Value
I represent the resources listed above are and will remain available for payment of services I may receive at St. Anne's Retirement Community
Have you ever been convicted of a crime other than a summary offense?
*
Yes
No
If Yes, What was the Date of the Conviction
If Yes, Please describe the Conviction
Agreement Signature
I have applied for admission to St. Anne’s Retirement Community. In doing so, I understand that St. Anne’s Retirement Community has a special obligation to clients, Residents and staff with respect to their personal property and safety. I hereby give St.Anne’s Retirement Community the right to make a thorough investigation into my previous employment, education, references, and character, and I release from all liability all persons supplying such information. The investigation is not limited to the above, and criminal checks both State and Federal-can be required. I authorize all public officials or persons involved in reference for admission to furnish information necessary for residency at St. Anne’s Retirement Community. Records obtained will be confidential. I hereby certify that the information and financial statements provided in this application are correct and complete to the best of my knowledge. I understand that any misrepresentation could result in the forfeiture of my application or status as a resident of St. Anne’s Retirement Community, Inc. I understand that this application does not obligate St. Anne’s Retirement Community, Inc., in any way and is submitted to be placed on file, and that the above information is strictly confidential. In the event a resident becomes a danger to themselves and/or others, as in the judgment of the attending physician and Administrator, to jeopardize the health and/or safety of other residents or constitutes a hazard to himself/herself, St. Anne's Retirement Community shall cooperate with the relative or responsible party in finding the most appropriate placement for the Resident.
By choosing I agree, you are legally signing an admission application to St. Anne's Retirement Community.
*
I Agree
Type in your name to digitally sign.
*
First
Last
Today's Date and Time
*
Date
Time
Submit