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ASSISTED LIVING apply now
Residency Application
Sex
Female
Male
Birthplace:
Insurance :
Part A:
No
Yes
Part B:
No
Yes
Medicare Advantage Insurance
No
Yes
Secondary Health Insurance:
Marital Status:
Single
Married
Widowed
Divorced
Primary Contact:
Power of Attorney:
Is power of attorney the same as primary contact?
No
Yes
Other Emergency Contact
Place of Worship
Funeral Home Contact
Other Information
US Citizen
Yes
No
Military Background
Yes
No
Applicant Status
Applicant is applying for residency at Bayley for:
Cottage / Independent Living
Assisted Living
Meadows, Woodlands- early stage Alzheimer’s/ Dementia Care
Health Care
Middle to late stage Alzheimer’s/ Dementia Care
Applicant is currently living:
Own home
Apartment
With friends or family
Nursing Home (Name of facility)
Other, please specify
Applicant is:
Participant of Bayley Adult Day Program
Attended Seton High School
Attended Mount St. Joseph University
Other association with SOC
When is the ideal time that the applicant would like to move into Bayley?
As soon as possible
In three to six months
Within the current year
More than two years from now
Financial Statement
Monthly Income
Monthly Expenses
Assets
Liabilities
Do you have Medicare Coverage?
Part A
Yes
No
Part B
Yes
No
Have you transferred property in the past 5 years?*
Yes
No
Are any of your assets held in a trust?*
Yes
No
If you currently own your home, will you be selling it?*
Yes
No
What will be the sources of payment for your residency at Bayley?
Own Assets
Trust
Family (identify)
Other (identify)
Do you have funeral expenses prepaid? *
Yes
No
* These questions must be answered or the financial application process could be delayed.
Please note that additional information may be requested at a later date.
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