Application for Admission

Name:

Mr. Mrs. Ms.

Name used by Applicant (nickname, first name):
Previous Address:		Postal Code:
Phone Number:		Religion:
Date of Birth:		Place of Birth:
Medicare #:		Medicare Exp. Date:
Social Insurance #:		Prescription Drug #:
Old Age Security #:		Blue Cross Plan:
Blue Cross Group:		Blue Cross Contract:
Blue Cross Class:
Marital Status:		Name of Spouse:

Name, Address and Phone Number of Individual representing Applicant (Sponsor) & in case of Emergency:

Name:		Relationship to Resident:
Address:		City:
Postal Code:		Phone #:

Other Persons to be Contacted in Case of Emergency

Name:		Relationship to Resident:
Address:		City:
Postal Code:		Phone #:

Name:		Relationship to Resident:
Address:		City:
Postal Code:		Phone #:

Name:		Relationship to Resident:
Address:		City:
Postal Code:		Phone #:

Are Funeral Expenses Prepaid:	Yes No
Funeral Director Designated:		Name:
Address:		Phone: