This application must be fully completed in order to be placed on the waiting list for admission. Please complete the application and return it to Four Winds Manor as soon as possible (faxed copies are acceptable). If there are any questions, please contact Social Services.

Social Services will need copies of all insurance information. This includes copies of Medicare, Social Security, and Private Insurance, forward card (if applicable). If available, can photo copy cards, otherwise please bring all the cards on the day of admission.

In completing this application, I am aware that Four Winds Manor will rely upon, and is entitled to rely upon, the accuracy of my statements. I understand that I may be requested to update this application when considered appropriate. Therefore, I DECLARE THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE, FULL, AND COMPLETE AND THAT THE ASSETS ARE AVAILABLE FOR MY CARE.

I give my consent to verify information contained in this application. I understand that medical information may be obtained as part of the pre-admission process and allow for the release of this information as needed.

Four Winds Manor reserves the right to accept or deny applicant for admission. Guidelines for acceptance and participation in facility programs are the same for everyone without regard to race, color, religion, national origin, age, sex, or disability