Children/Significant Other (Please list individuals in the order they should be contacted if unable to reach POA)
Primary Health Insurance (Medicare, Advantage Plan, PPO)
Secondary Health Insurance
Power of Attorney
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.
Real Estate Owned
Please provide the locations of each property owned and its 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
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.