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YOUR CART
Independent Living Resident Application
First Applicant
Please note: fields with a red asterisk
*
are required. If you click submit at the end of this form, and do not see a confirmation message, we have not received your submission, and you should review your form for areas with an asterisk
*
that you may have missed and click the Submit button again.
*
Indicates required field
Name
*
First
Last
Date
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Social Security Number
*
Preferred Phone Number
*
Cell Phone Number (if different)
*
Email
*
Gender
*
Female
Male
Other
US Citizen?
*
Yes
No
Dual Citizenship
If not a US citizen, or have dual citizenship, what is your citizenship?
*
Second Applicant
Name
*
First
Last
Date
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Social Security Number
*
Preferred Phone Number
*
Cell Phone Number (if different)
*
Email
*
Gender
*
Female
Male
Other
US Citizen?
*
Yes
No
Dual Citizenship
If not a US citizen, or have dual citizenship, what is your citizenship?
*
Type of residence desired
*
Townhome
Co-housing Apartment
If townhome, I would like:
*
Two bedrooms
Two bedrooms with den
If co-housing, I would like:
*
Studio
One bedroom
Two bedrooms
Two bedrooms with den
Individuals to be contacted for future correspondence:
Name
*
First
Last
Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Relationship
*
Choose Any
*
POA
Healthcare Proxy
Guardian
Authorized to assist with finances?
*
Yes
No
Additional individual to be contacted for future correspondence:
Name
*
First
Last
Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Relationship
*
Choose Any
*
POA
Healthcare Proxy
Guardian
Authorized to assist with finances?
*
Yes
No
Confidential Financial Statement
Applicant 1
Earned income (monthly)
*
Social Security Benefits
*
Veteran's Benefits
*
Other Pension (specify)
*
Railroad Retirement
*
Annuity
*
Other (specify)
*
Net Monthly Income
*
Applicant 2
Earned income (monthly)
*
Social Security Benefits
*
Veteran's Benefits
*
Other Pension (specify)
*
Railroad Retirement
*
Annuity
*
Other (specify)
*
Net Monthly Income
*
List all assets you intend to use to pay for your living expenses at Camphill Ghent (i.e. bank/investment accounts):
Institution
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Account Number
*
Balance
*
Institution
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Account Number
*
Balance
*
Institution
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Account Number
*
Balance
*
Please list any additional accounts/details here
*
Do you have any CDs?
*
Yes
No
If yes, what is the value?
*
Do you own stocks or bonds?
*
Yes
Option 2
Option 3
If yes, what is the value?
*
Do you own real estate?
*
Yes
No
If yes, what is the value?
*
Do you plan to sell your principal residence or other real estate to pay for your financial obligations while at Camphill Ghent?
*
Yes
No
Please list any other assets:
*
By clicking the "Submit" button below, I am agreeing to the following: I understand that Camphill Ghent relies upon the accuracy of the above information for the purpose of determining whether there will be a source of payment and to determine when the resident may need financial assistance. I hereby give Camphill Ghent permission to verify financial information supplied on this application for admission.
Please note: fields with a red asterisk
*
are required. If you click submit at the end of this form, and do not see a confirmation message, we have not received your submission, and you should review your form for areas with an asterisk
*
that you may have missed and click the Submit button again.
Submit
