Application For Residency

(The Village at Morse Farm holds all the following information in confidence.)

General Information

Emergency Contact

In case of an emergency please contact:

Is the above individual designated as Power of Attorney or Guardian?

Background Screening Information

As part of the determination for eligibility, The Village at Morse Farm will screen all applicants according to State and Federal Regulations as well as the policies of The Village at Morse Farm. This screen may include, but is not limited to criminal background, sex offender registration and credit reporting.

Health/Medical Information

Release of Medical Information:

In case of an emergency, (e.g., ambulance, hospital services), I authorize The Village at Morse Farm to release medical information to outside medical services.

Signed:

Supplemental Insurance Information:

Agreement Information

I (We) fully understand that the above information is correct. I (We) also understand that I (We) must be physically, mentally and socially able to maintain myself (ourselves) as an independent resident(s) of The Village at Morse Farm.

Signature of Applicant:

Signature of Applicant: