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Online Application for Residency

Application for Residency

Accommodations Desired(Required)

Personal Care Shared Room with Shared Bathroom

Personal Care Private Room with Shared Bathroom

Personal Care Private Room with Private Bathroom

Name of Applicant(Required)

First Last

Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Place of Birth (Township/County/State)(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Social Security Number(Required)

Medicare ID

Marital Status(Required)

Never Married

Married

Widowed

Divorced

Medicare Supplement

Policy Number

Pace Card No.

Effective Date

Untitled

Physician Name

Physician Phone

Religious Preference

Church

If appointed, Power of Attorney

Power of Attorney Phone

Power of Attorney Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Allergies

Diagnosis

Special Dietary Needs

Ambulation Device (Choose One)(Required)

Independent

Cane

Walker

Wheel Chair

Able to use stairs?(Required)

Yes

No

Care Needs (select all that apply)

Toileting

Bathing

Dressing

Oral Care

Medication Administration

Persons (spouse, children or significant other) to be contacted if unable to get in touch with applicant. Please provide name, relationship to applicant, email address and phone number.

The applicant will be contacted when the desired accommodation is available. If someone other than the applicant should be contacted, put the word PREFERRED in front of that person’s name.

Preferred Funeral Director

Preferred Funeral Director Phone Number

Is the burial pre-paid?

Yes

No

Do you have a burial space?

Yes

No

Have you assigned and/or transferred any assets for less than fair market value within the last five (5) years?

Yes

No

If yes, please explain (include value of assets)

Asset Dollar Amount

Checking & Savings

Certificate of Deposit

Other

Total Asset Amount

Applicant's Monthly Income

Social Security

Pensions

Dividends & Interests

Other

Total Monthly Income

Liabilities

Credit Card Debt

Notes Payable

Other (specify)

Description of Real Estate

Please include Property & Location, Approximate Date Acquired, Approximate Purchase Price, Remaining Mortgage, and Fair Market Value

Additional information or concerns we should be aware of:

How did you hear about us, or who referred you to Welsh Mountain Home?

Consent(Required)

I agree

I certify the information provided on this application to be true and correct and authorize Welsh Mountain Home to research any above information for verification. I understand that Welsh Mountain Home may request proof of financial status. I understand that this application is not binding on Welsh Mountain Home or me. It simply expresses my interest in becoming a resident and submitted to be placed on file; all information is held in strict confidence.

Today's Date

MM slash DD slash YYYY

Testimonials

“God is with me and He led me here. That is all that I can say. I’ve been happy ever since.”

- Mattie, Welsh Mountain Home Resident

View All Testimonials

567 Springville Road
New Holland, PA 17557
717-355-9522
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