APPLICATION BLANK
FOR ADMISSION TO
GRANDVIEW RETIREMENT HOME
_______________
PHONE
To the Manager and the Board
of Directors: I hereby apply for
admission as a tenant of the above named facility. If admitted to the facility I promise to
cooperate and make life within the facility pleasant and agreeable, and to
comply with the rules and regulations.
1.
Name
..
Date
..
..
2.
Current address
.
.
3.
Phone Number
Birth date
.
4.
Name of Spouse
5. Power of Attorney/Conservator
..
6. Emergency contacts please list 2 or 3: names,
phone numbers and addresses:
7.
Food Allergies
..
I hereby certify that I have
carefully studied this application and understand it in detail, and that I have
answered correctly to the best of my knowledge and belief all questions herein
contained.
__________________________________________
Applicant