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Application for Admission
 Personal Information
Full Name
Mailing Address:
 
City  
Zip Code
Phone Number -  
Date of Birth (MO/DD/YR)
Marital Status
Married
 
  
 Spouse Information (if applicable)
Name of Spouse
Spouse Phone Number -  
Spouse Mailing Address:
 
City  
 Primary Contact (in case of sickness or accident)
Name
Address:
 
City  
Zip Code
Daytime Phone Number -  
Evening Phone Number -  
Relationship
 Secondary Contact (in case of sickness or accident)
Name
Address:
 
City  
Zip Code
Daytime Phone Number -  
Evening Phone Number -  
Relationship
 Legal Information
Name of Attorney
Address:
 
City  
Zip Code
Phone Number -  
 Insurance
Primary Insurance Plan
Contract Number  
Plan Code  
Service Code  
Social Security Number  
*** Other Insurance Plan
Group Number  
Service Code  
Contract Number  
Plan Code  
Medicare Number   Effective date (MO/DD/YR)
Medicaid I.D. Number   Medicaid Case Number
Veterans Number and status
 Medical Information
Physician's Name
Address:
 
City  
Zip Code
Phone Number -  
Number of Years with...  
Previous Physician
 Funeral Arrangements
Funeral Director
Address:
 
City  
Zip Code
Phone Number -  
How did you hear about us?
I have read and I understand the Residents Bill of Rights. I understand and agree that Community Village and its owners have the exclusive and final right to decide if my application for residency will be accepted and that the Village and its owners have the final and exclusive right to determine how long I can continue to reside at the Village.

Community Village does not discriminate on the basis of race, religion, color,
national origin, sex, age, handicap, marital status or sexual orientation.
 
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