Resident Application

Filing Information
Last Name
 E-mail Address
 Medicare #
Room Type:  Semi-private Private
Accommodation desired:
 Cottage Nursing Care Special Care Assisted Living
Applicant Information
First Name
 Middle Name
 Phone #
Street Address
 City
 State
Birth Date
 Birth Place
 Church Affiliation
I wish to enter North Adams Home...
 At Once At a Later Date 		Desired Move-in Date
I am seeking admission for the following reasons
Family
Marital Status  Married Widowed Divorced Single
Name of Spouse
 Occupation of Spouse
 Date of Marriage
Father's Name
 Mother's Maiden Name
Children
Name of 1st born
 Address
 City, State
Phone Number
 Cell/Work Number
  
Name of 2nd born
 Address
 City, State
Phone Number
 Cell/Work Number
  
Name of 3rd born
 Address
 City, State
Phone Number
 Cell/Work Number
  
Names, addresses, and
telephone numbers of other
persons who should be
notified in case of
emergency.
Health and Wellness
I am physically able to care
for myself with: 		 Bathing Dressing Toileting Eating
Physician Name
 Physician Telephone
 Last Physician Appointment
Dentist Name
 Dentist Telephone
 Last Dental Appointment
Foot Doctor Name
 Foot Doctor Telephone
 Last Appointment
Eye Doctor Name
 Eye Doctor Telephone
 Last Appointment
Preferred Hospital
 Hospital Telephone
 Last Visit
Funeral Director Name
 Funeral Director Telephone
 Pre-paid Burial?
 Yes No
Do you agree to submit a physical examination
report?
 Yes No 		Organ Donor?
 Yes No
Education / Experience
Grade School Name
 Grade School City, State
 Grade School Years
High School Name
 High School City, State
 High School Years
College Name
 College City, State
 College Years
Other Training
 Years Trained
Previous Employer
 Job Title/Description
 Number of Years Worked
Were you a member of
the Armed Services? 		 Yes No If so, which war?
List any experiences that
have contributed to the
development of your
character or gave extra
pleasure to you. You may
also choose to list places to
which you have traveled:
List any hobbies or interests
that you have:
Power of Attorney
Health Care POA Name
 Health Care POA Address
 Health Care POA Phone
Financial POA Name
 Financial POA Address
 Financial POA Phone
References
Reference 1 Name
 Reference 1 Address
 Reference 1 Phone
Reference 2 Name
 Reference 2 Address
 Reference 2 Phone
Reference 3 Name
 Reference 3 Address
 Reference 3 Phone
Additional Information
If, after being admitted into North Adams Home, I should suffer mental ailments making it expedient to terminate my stay, I agree to be transferred to some other suitable institution on the advice of my physician and in counsel with my family or sponsor.
 Yes No
If, after being admitted into North Adams Home, it becomes necessary to be moved to a higher or lower level of care, I agree to be transferred to that area on the advice of my physician and in counsel with the members of my family or sponsor.
 Yes No
I certify that the information called for herein is complete, honest and accurate. I further agree to keep North Adams Home informed at all times of any changes of address, condition or plans.
 Yes No


If assistance is needed in completing this application, please contact Kathie Palmer @ 217-936-2137 or email naham@adams.net.