LUCY BOARDMAN RESIDENCE ADMISSION APPLICATION


Please find enclosed this facility's written application form. As soon as you substantially complete and return the form to the facility, your name will be placed on our waiting list for admission to the facility. Your name will only be placed on our waiting list after you substantially complete and return this written application form to us.

 

PERSONAL INFORMATION

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RESPONSIBLE PARTY

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Does Anyone Hold:


CONFIDENTIAL HEALTH HISTORY


Please list dates and nature of major illnesses, hospital stays, operations or therapy treatments:

What medications do you use?

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MEDICAL & SOCIAL INFORMATION


 


CONFIDENTIAL FINANCIAL INFORMATION


INSURANCE

APPLICANT'S ASSETS

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Donations

Mary Wade gratefully accepts donations for all services provided.

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Applications

Fill out the appropriate form for admission to the Mary Wade Home.

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or contact us with questions.