Admissions Application

Type of Care Required

Private Pay Long-term Care

Transitional Care

Respite Care

This is only an application for residency and services. It is not to be deemed as approval of admission. I understand the facility reserves the right to screen and evaluate applicants. I hereby declare the information is true and correct.

Yes

Applicant must be aware of the Consent to Facility Admission Act.

Yes

I certify that all information provided in this application is accurate, true and complete to the best of my knowledge, and I understand that intentionally providing false information could result in refusal of application for accommodation and residency and/or future notice of eviction.

Yes

I understand that it is my responsibility to advise Evergreen of any changes to the information given above.

Yes

Once the applicant is #1 on the waitlist, a $500 deposit is required within 24 hours of notification and acceptance of this position on the waitlist.

Yes

If accommodation is canceled following acceptance of the #1 spot, the following applies: • Cancellation post acceptance of #1 position but greater than 72hrs before admission$425.00 refund. • Cancellation 72hrs before admission $300.00 refund. • Cancellation 48hrs before admission $250.00 refund. • Cancellation 24hrs before admission $125.00 refund. • Cancellation less than 24 hrs before admission - no refund.

Accept

Applicants Name:

First Name

Last Name

Date of Birth:

MM

DD

YYYY

Current Location of Applicant:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is the applicant aware of the plan for admission:

Yes

No

Requested Admission Date:

MM

DD

YYYY

Safety Management: (check all that apply)

Anticoagulant (blood thinner) therapy

History of aspiration/choking

Needs medications crushed

Limited/non-weight bearing

History of a pressure ulcer

History of seizures

Special Diet

Smokes

Alcohol/drug Use

May leave without notifying staff/May Attempt Exit without notifying

Suicidal or history of suicide attempt

History of falls

History of inappropriate behaviour/disinhibition

Harm to self or others

Person responsible for financial decisions and Contact Person:

First Name

Last Name

Phone Number (where you can be reached within 2 hours regarding a vacancy): Contact #1:

(###)

###

####

Phone Number (where you can be reached within 2 hours regarding a vacancy): Contact #2:

(###)

###

####

Third Party Payer (check all that apply)

Veterans Affairs Canada (VAC)

Indigenous and Northern Affairs Canada

Work Safe BC

Extended Health Care (Blue Cross, Green Shield, etc.)

By signing this agreement, I certify the information to be accurate and I acknowledge the fees charged for staying at Evergreen Seniors Home Inc. I agree to pay these fees. I certify that the information provided on this form is true and accurate:

First Name

Last Name

Name of Resident/Most Responsible Party:

First Name

Last Name

Date

MM

DD

YYYY