We are excited by the prospect of having you or your loved one join our community. Please fill out the application below in it's entirety.

Potential Resident's Name
Potential Resident's Name
Potential Resident's Current Address *
Potential Resident's Current Address
Potential Resident's Phone Number *
Potential Resident's Phone Number
Potential Resident's Date of Birth *
Potential Resident's Date of Birth
Did resident serve in the US Armed Forces?
Does the potential resident have a history of substance abuse?
Applicant's Personal and Family History
The next section focuses on the resident's spouse/partner, children and family.
Spouse Legal Name
Spouse Legal Name
Spouse Address
Spouse Address
Spouse Date of Birth
Spouse Date of Birth
Please include child's name, address, phone number and relation to potential new resident.
List the resident's sibling name, address, phone number and relation
Applicant's Legal Information
The following questions will address the applicant's insurance, living will and power of attorney
Please list information for: Part A Part B Part D
Please list all other health insurance policies other than Medicare (include dental and prescription benefits)
List all life insurance policies. Please include company name, policy number and amount.
Include name, telephone number, complete address and relationship
Funeral Home, address, telephone number. Also include the cemeteryname and address.
Applicant Financial Information
The final section address the applicant's financial information. Also please be prepared to furnish 3 years worth of banking statements and tax returns.
Please include the amount, institution, account number and address for bank.
Please include the amount, institution, account number and bank address
Please include institution
Please include institution
Government Bonds Amount Savings Bond Amounts C.D's Amounts IRA's Amounts Stock/Investments Amounts Long Term Care Policy Amounts
Please include address, joint owners (if applicable) and estimated value
Does the resident have any mortgages in their names? Also include the mortgage amounts.
If so, please explain
Submission
We thank you for submitting your application to Mountainside Senior Living. By clicking on the button below, you certify that the application is true, correct and accurate. All information will be kept confidential.