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EDUCATION
CHAPEL SERVICES
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Application for Residency
Application for Residency
Chris Sisk
2017-11-12T22:53:54-06:00
Step
1
of
4
25%
Choosing a Campus
I am ready for admission as soon as an opening occurs?
Yes
No
Please select the location(s) you prefer.
*
Adrian
Arcadia Valley
Ashland
Chillicothe
Independence
Ozark
If more than one location is preferred, please indicate 1st and 2nd Choice
Option 1
Option 2
Please share briefly why you prefer this campus.
*
Living Situation for Residency
Active (Independent Living) - Resident must be able to fully care for themselves. Light housekeeping and all yard work and apartment repairs provided.
Assisted Living - Licensed care for those needing minimal assistance. Meals and housekeeping provided. (Not yet available in Adrian or Ashland)
Nursing Care - Nursing staffed 24 hours/7 days and access to medical services available through area physicians. (Not yet available in Adrian or Ashland)
Arcadia Valley Preferred Unit
1 Bed/ 1 Bath: Chalet
2 Bed/ 1 Bath: Chalet
2 Bed/ 2 Bath: Chalet
2 Bed/ 2 Bath: Bungalow
Ashland Preferred Unit
3 Bed/2 Bath/2 Car Garage - Patio Home
2 Bed/2 Bath/1 Car Garage - Bungalow
1 Bed/1 Bath - Congregate Living
Chillicothe Preferred Unit
2 Bed/ 1 Bath: Chalet
2 Bed/ 2 Bath: Bungalow
Ozark Preferred Unit
3 Bed/ 2 Bath: Patio Home
2 Bed/ 2 Bath: Bungalow
Potential Resident Information
Name (First Applicant)
First
Middle
Last
Spouse Name (Second Applicant)
First
Middle
Last
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone Number
Cell Number
Email
Veteran?
Yes
No
Military Branch?
Veteran's Spouse/Widow?
Yes
No
Spouse/Widow Military Branch?
Marital Status
Never Married
Married
Widowed
Divorced
Spouse's Name
First
Last
Marriage Date
Month
Day
Year
Church Membership
Church Name
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Church Phone
Phone number for your current church
Physician's Name
Name
Physician's Phone
Legal Information
Do you have health insurance?
Yes
No
What kind of health insurance?
Medicare
Medicaid (MO Healthnet)
Supplement
Long-term care insurance?
Yes
No
Pre-paid funeral arrangement?
Yes
No
Do you have a Durable Power of Attorney (POA) or Legal Guardian?
Yes
No
Name of POA or Guardian
Name
Phone number of POA or Guardian
Do you have an Estate Plan?
Yes
No
Do you have an Advanced Health Care Directive?
Yes
No
Have you disposed of any assets other than customary living expenses?
Yes
No
Reason for disposal?
Do you anticipate needing financial assistance within the next 5 years?
Yes
No
*You will need to complete a financial application. Upon completion of this form, you will be directed to download the application. If you have an email address, you will also be e-mailed the form with instructions on how to turn it in.
Please add me to the list for news and information about The Baptist Home
Yes
No
I HEREBY AFFIRM that I am submitting this Application for Residency to The Baptist Home of my own free will and the information herein is true and correct to the best of my knowledge. I will abide by the Admissions Policy, in which, I have not or will not transfer or give away any real or personal assets other than for customary living expenses that otherwise could cause me to require benevolent assistance in the future. I understand that my name will be added to the application data base and all admissions are based on availability and type of residency. I understand the completion and submission of the Application for Residency does not imply or guarantee residency at The Baptist Home. The Baptist Home reserves the right to refuse admission to any person whose needs cannot be met by the facility.
I agree
*
Yes
No
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