Applicant Information

Medical Providers

Primary Physician

Dentist

Pharmacy

Hospital

Insurance Information

Documents

Does the applicant have the following? If marked “yes,” please upload copies of the documents.

Documents

In case of emergency, please notify the following (Please list in order of preference).

Contact #1:

Contact #2:

Contact #3:

Person Responsible for Account

Please provide documentation of financial POA

Financial Statement

Applicant – Monthly Income

Spouse – Monthly Income (if applicable)

Assets owned jointly and separately by the admitting applicant and other person(s) which are available to the applicant only:

Person Responsible for Account

I certify that the information I have provided in the foregoing application is true and correct and that I am signing as the responsible party. I have either been authorized to provide the information contained in this application or am acting as the applicant’s guardian and/or conservator. I understand that the Trinity Center at Luther Park Community is relying on the accuracy of the information provided in this application in order to make a decision on admission. I understand and agree that any misrepresentation of any information provided in this application is grounds for rejection of this application. I further understand and agree that if any misrepresentation of any information provided in this application is discovered after admission, and admission would not have been granted if the correct information had been provided. The Trinity Center at Luther Park Community reserves the right to pursue any legal, equitable, or other remedies it may have against the applicant and/or responsible party signing the application below on behalf of the applicant.

I further understand that the Trinity Center at Luther Park Community is committed to promoting good health and safety among its residents and, therefore, SMOKING BY RESIDENTS IS PROHIBITED ON FACILITY PROPERTY.