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 #:
Email Address:

Other Persons to be Contacted in Case of Emergency

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

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

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

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