Application for Admission

Applicant(s)

Title(Required)

Mr.

Mrs.

Miss.

Name of Applicant(s)(Required)

Current Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Cell Phone(Required)

Email(Required)

Date of Birth(Required)

Birth Place/State(Required)

Age(Required)

Marital Status(Required)

Single

Married

Widowed

Divorced

Social Security #(Required)

Medicare #(Required)

Co-Insurances(Required)

Co-Insurance Policy #(Required)

Co-Insurance Location(Required)

City State / Province / Region ZIP / Postal Code

Have you ever served in the armed services?(Required)

Yes

Has your spouse ever served in the armed services?(Required)

Yes

Medical Providers

Physician Name(Required)

First Last

Physician Address(Required)

Street Address Address Line 2 City State ZIP Code

Physician Phone(Required)

Dentist Name(Required)

First Last

Dentist Address(Required)

Street Address Address Line 2 City State ZIP Code

Dentist Phone(Required)

Pharmacy Name(Required)

Pharmacy Address(Required)

Street Address Address Line 2 City State ZIP Code

Pharmacy Phone(Required)

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Hospital Phone(Required)

Applicant was referred by:(Required)

Documents

Does the applicant have the following? If marked "yes," please provide copies of the documents.

Living Will(Required)

Yes

Upload copy of living will(Required)

Max. file size: 64 MB.

Name of POA's, Conservator, Guardian(Required)

Physician statement enacting POA's(Required)

Yes

Upload copy of physician statement enacting POA's

Max. file size: 64 MB.

Name of POA's(Required)

General Power of Attorney(Required)

Yes

Upload copy of General Power of Attorney(Required)

Max. file size: 64 MB.

Name of POA's(Required)

Healthcare Power of Attorney(Required)

Yes

Upload copy of Healthcare Power of Attorney(Required)

Max. file size: 64 MB.

Name of POA's(Required)

Financial Power of Attorney(Required)

Yes

Upload copy of Financial Power of Attorney(Required)

Max. file size: 64 MB.

Name of POA's(Required)

Conservator(Required)

Yes

Upload copy of conservator document(Required)

Max. file size: 64 MB.

Name of Conservator(Required)

Guardian(Required)

Yes

Upload copy of guardian document(Required)

Max. file size: 64 MB.

Name of Guardian(Required)

Pre-paid Burial(Required)

Yes

Upload document(Required)

Max. file size: 64 MB.

Name of POA's, Conservator, Guardian(Required)

Preferred Funeral Home(Required)

Street Address Address Line 2 City State ZIP Code

Funeral Home Phone(Required)

Emergency Contacts

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

Contact #1 Name(Required)

First Last

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship(Required)

Work Phone #(Required)

Home Phone #(Required)

Cell Phone #(Required)

Contact #2 Name

First Last

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship

Work Phone #

Home Phone #

Cell Phone #

Contact #3 Name

First Last

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship

Work Phone #

Home Phone #

Cell Phone #

Contact #4 Name

First Last

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship

Work Phone #

Home Phone #

Cell Phone #

Person responsible for account

Please provide documentation of financial POA

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship(Required)

Work Phone #(Required)

Home Phone #(Required)

Cell Phone #(Required)

Financial Statement

Monthly income - applicant

Social security(Required)

Pension(Required)

Interest & Dividends(Required)

Other Income(Required)

Total Monthly Income(Required)

Add the previous 4 lines

Monthly income - spouse (if applicable)

Social Security

Pension

Interest & Dividends

Other Income

Total Monthly Income

Add the previous 4 lines

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

Real Estate(Required)

Enter dollar amount

All other assets(Required)

Enter dollar amount. ie: stock bonds, mutual funds, savings accounts, Certificate of Deposits, etc.

Less: Off-Setting Liabilities(Required)

Enter dollar amount

Net Assets owned which are available to the applicant only(Required)

Enter dollar amount

For admitting the applicant only

Name of Insurance Company(Required)

Insurance Company Address(Required)

Street Address Address Line 2 City State ZIP Code

Insurance Company Phone(Required)

Policy #(Required)

Confirmation

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 Gardens 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 Gardens 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 Gardens 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.

Signature (type name)(Required)

Today's Date(Required)

Applicant(s)

Medical Providers

Documents

Emergency Contacts

Person responsible for account

Financial Statement

Confirmation

Senior Living Options

Luther Park - Prefooter