Application For Residence

Do you have or have you had any of the following diseases or problems?

Power of Attorney for Healthcare: (Please supply a copy):

Living Will (Please supply a copy):

Legal Will

Executor of Estate:

The assets listed in this application are controlled by me (us) in my (our) individual or joint names and held for my (our) benefit. We are prepared to pay for all levels of care at Elm Terrace Gardens. I (We) understand and acknowledge that Elm Terrace Gardens relies on the information and disclosures made in this application for the purpose of inducing Elm Terrace Gardens to consider me (us) for admission. I (We) certify that the information and disclosures provided in this application are true, correct and complete to the best of my (our) knowledge.

Elm Terrace Gardens, a nonprofit corporation, serves older adults by providing independent living, personal care and skilled nursing services in a safe, caring, attractive, stimulating and spiritually nourishing environment. Accordingly, we seek the highest levels of resident well-being in the context of state-of-the-art long term care.