Application for Admintance

Please fill out the form below and submit. A representative from the Shirley Home will be incontact with you to discuss admitance.

Name

Date

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Social Security Number

County of Residence

Years at this Residence

Citizen of the U.S.YesNo

If not, how long have you been at this residence

Date of Birth

Age

Place of Birth

Age Verification

SexMaleFemale

Referral Source

Spouse Name

If Living, Where?

If deceased, how long

Date of Marriage

Place of Marriage

Children name/phone (list one child & number per line)

Other Interested Relatives or Friends

If known, list name of applicant’s parents and birthplaces

Emergency Contact

In case of an emergency, please indicate the person(s) to be notified

In case of an emergency, please indicate the person(s) to be notified

Name

Phone

Relationship

Name

Phone

Relationship

Education and Work History

Number of years in public school completed:

Diploma/GEDDiplomaGED

College

Field of Study

Kind of work done most of your life, even if retired at present

Church

Has the applicant been active in church recently or in the past?YesNo

Religion

Church Affiliation

Minister

Interests & Activities

List particular skills, hobbies or special interest

List known preferred activities in which the applicant takes part in (past or present)

Social Service Information

If someone other than the applicant is completing this application, has the applicant been informed and given his/her consent for admission to the facilityYesNo

If not, please explain

What is the attitude of the applicant regarding Shirley Home care?

What do you think would provide the most assistance to the applicant in adjusting to the Shirley Home?

Medical Information

Family Physician

Physician's Phone Number

Will applicant be switching to Southern Huntingdon Medical CenterYesNo

Name of Hospital to use in case of emergency if not Penn Highlands Hospita

Member of an ambulance service?YesNo

Optometrist

Podiatrist

Dentist

Last Hospitalization

Name of Hospital

Reason for Hospitalization

Date of Last Tetanus Shot

Date of Last Flu Shot

Date of Last Pneumococcal Shot

Date of Last TB Shot

Date of Last Shingle Shot

Covid Vaccine #1

Covid Vaccine #2

Booster Shot #1

Booster Shot #2

Date of last Colonoscopy

Date of last Mammogram

Describe briefly the present health status

Medical Coverage

(A copy of all cards must be presented on admission)

MedicareYesNo

Medicare Number

Medicaid

Medicaid Number

Other Health Insurance Name

Other Health Insurance Number

Does the applicant have a willYeaNo

In whose possession is it

Does the applicant have a living will?

In whose possession is it

Does the applicant have an Advanced Directive?

In whose possession is it* A copy will be required on admission.

Financial Report of Applicant

Financial report must be completed before admission. Supply complete information for every space. Do not leave blanks.

Person responsible for applicant’s personal and financial affairs (Guardian or POA)

First Name

Middle Name

Last Name

Phone

Relationship

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Person responsible for applicant’s personal and financial affairs (Guardian or POA)

First Name

Middle Name

Last Name

Phone

Relationship

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Responsible Party to pay Room and Board

Name

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Income and Assets

Social SecurityYesNo

Amount

SSI

Amount

Railroad

Amount

Claim Number

Veterans

Amount

Claim Number

Other benefits or pension payments (specify)

Amount

Who is the payee for checks?

Mental Status of Applicant

Is the applicant capable of signing own name?YesNo

Checking Account?YesNo

Place of Account

Checking Account Balance

Savings Account?YesNo

Place of Account

Savings Account Balance

Cash on hand, in home, in safe deposit box, etc.?YesNo

Balance

U.S Gov't Bonds?YesNo

Number of Bonds

Value

Source #1

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Source #2

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Stocks and other securities

Name of Company

Value

Has the applicant transferred any assets to another person in the last two years?YesNo

If so, what

Value

Does the applicant have any personal property – such as furniture, automobile, etc.

Value

Real Estate

Does the applicant own any real estate?YesNo

Type of PropertyResidentialRental

Income received from Rental Property

Describe what the real estate consists of (buildings, land)

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Life Insurance

Does the applicant have life insurance?YesNo

If so, type?

Company

Policy Number

Beneficiary

In Case Of Death

Does the applicant have a burial plan?YesNo

Who will be responsible for burial plans

Phone

Name of funeral home to be contacted

Phone

Discharge Planning

When resident is no longer able to stay at Shirley Home, who will be assisting the applicant to find continued care is provided at the time of discharge?

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I do swear that I know and understand the contents of the financial statement. That I have not knowingly made any misrepresentation herein, and that the contents hereof are true, correct and complete to the best of my knowledge and understand

Applicant or POA

Date

I do swear that I know and understand the contents of this application. That I have not knowingly made any misrepresentation herein, and that the contents hereof are true, correct and complete to the best of my knowledge and understanding.

Applicant or POA

Date

List of items needed at time of admission: Insurance cards, Social Security Card, Driver’s License or Identification card, bank statement and POA papers.