Masonic Village Application
X Elizabethtown Lafayette Hill Sewickley Warminster
All Masonic Villages are Non-Smoking
This application will be cancelled 1 year from date of issue if not processed
This application is being submitted for:
Personal Care = Minimal assistance with tasks of daily living, bathing, dressing, medication administration, appointment management (1 hour per day.)
Nursing Care = Moderate to maximum assistance with tasks of daily living
Memory Support/Nursing Care = Moderate to maximum assistance with tasks of daily living, with a memory support area available for those in need at the Elizabethtown and Sewickley facilities.
My desired time frame is (check one):
❑ immediately ❑ in 1 year ❑ in 2 years ❑ in 3 years ❑ longer
Name of Applicant Masonic/Eastern Star Affiliation
Name of PA Mason/PA Eastern Star Member Initiation Date
Lodge or Chapter Name/#/Location
Failure to complete the application in its entirety or sign below can result in a delay in processing your application
❖ I certify the information contained in this application is correct and complete to the best of my knowledge and the resources listed are and will remain available to pay for all services provided by Masonic Village.
❖ I will not make any transfers or gifts subsequent to the date of this application for residency, including a transfer of assets to an irrevocable trust, or change the liquidity of my assets in any manner, including the purchase of an annuity, which would substantially impair my ability to timely fulfill my financial responsibility and financial obligations to Masonic Village. This provision will be enforced to the extent permitted by applicable law.
❖ I understand that any misrepresentation or willful omission of information on this application will disqualify the applicant for admission and may be cause for discharge if discovered after resident’s admission.
❖ I understand Masonic Village will screen all applicants against the applicable Megan’s Law website.
❖ Financial documentation & Medical Information must be provided as part of the application process
Signature of applicant and/or person completing this application:
Applicant Person completing application
Date Date
Decisions concerning admission, the provision of services and referrals of residents are not based on the applicant’s race, color, religion, disability, ancestry, national origin, familial status, age, sex, limited English proficiency (LEP) or any other protected status
FOR OFFICE USE ONLY
Application # Date Issued Megan’s Law
PC NC Approved: Wait List Denied
NC-MS Rehab Stay Hold
Signature Date
Full Name Sex M F US Citizen Yes No
Date of Birth: Place of Birth
Address City State Zip
Type of Residence: Own Rent Live with family Personal Care Nursing Care
Home Phone # Cell Phone #
Email address
Previous Address
Veteran Yes No or Spouse of Veteran Yes No Branch
Former Occupation Retirement Date
Religious Affiliation:
Marital Status:
1.Full Name of Spouse(living or deceased)
2.Full Name of Spouse(divorced or deceased)
Are you registered as: Organ Donor Lions Eye Bank Donor Humanity Gifts Donor
Medical Assistance #
Do you have Long-term Care Insurance? Yes No If yes, please complete information below:
Name of Financial Power of Attorney/Guardian
Address City State Zip
Home Phone # Cell Phone #
Email address
Name of Medical Power of Attorney/Medical Decision Person
Address City State Zip
Home Phone # Cell Phone #
Email address
NEXT OF KIN/EMERGENCY CONTACTS – APPLICANT #1
(Medical POA/Decision will be contacted first in event of serious illness or death)
1. Name: Relationship to Applicant
Address:
Phone: (H) (W) (C)
E-mail Address:
2. Name: Relationship to Applicant
Address:
Phone: (H) (W) (C)
E-mail Address:
3. Name: Relationship to Applicant Address:
Phone: (H) (W) (C)
E-mail Address:
FINAL ARRANGEMENTS – APPLICANT #1
Name of Funeral Home Phone #
Address
Have you prepaid arrangements into an Irrevocable Burial Fund?
Full Name Sex M F US Citizen Yes No
Date of Birth: Place of Birth
Address City State Zip
Type of Residence: Own Rent Live with family Personal Care Nursing Care
Home Phone # Cell Phone #
Email address
Previous Address
Veteran Yes No or Spouse of Veteran Yes No Branch
Former Occupation Retirement Date
Religious Affiliation:
Marital Status: Single Married Divorced Separated
1.Full Name of Spouse(living or deceased)
2. Full Name of Spouse(divorced or deceased)
Are you registered as: Organ Donor Lions Eye Bank Donor Humanity Gifts Donor
Do you have Long-term Care Insurance? Yes No If yes, please complete information below:
Name of Financial Power of Attorney/Guardian
Address City State Zip
Home Phone # Cell Phone #
Email address
Name of Medical Power of Attorney/Medical Decision Person
Address City State Zip
Home Phone # Cell Phone #
Email address
NEXT
OF
KIN/EMERGENCY CONTACTS –
APPLICANT #2 (Medical POA/Decision will be contacted first in event of serious illness or death)
1. Name: Relationship to Applicant
Address:
Phone: (H) (W) (C)
E-mail Address:
2. Name: Relationship to Applicant
Address:
Phone: (H) (W) (C)
E-mail Address:
3. Name: Relationship to Applicant Address:
Phone: (H) (W) (C)
E-mail Address:
FINAL ARRANGEMENTS – APPLICANT #2
Name of Funeral Home Phone #
Address
Applicant 1
MONTHLY INCOME
Within the past 5 years, immediately preceding the date of this application, have you or your spouse?
Had a judgment entered against you? Yes No
Paid bills for someone else? Yes No
Declared bankruptcy? Yes No
Transferred/Gifted Assets? Yes No
Opened a Revocable or Irrevocable Family Trust? Yes No
Had money or personal possessions taken without your knowledge? Yes No
Sold your interest in real estate, automobile, other assets? Yes No
If yes, to any of the above, please provide appropriate documentation, judgement, bankruptcy, trust documentation, settlement sheet, etc.
EQUAL HOUSING OPPORTUNITY STATEMENT
The Masonic Village is pledged to the letter and spirit of the U.S. Policy for the achievement of equal housing opportunity throughout the Nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status or national origin.
REQUIRED PERSONAL DOCUMENTATION – PLEASE PROVIDE COPIES
Social Security Card
Medicare Card (even if you have an HMO or PPO)
Supplemental Insurance Card
Medicare Advantage Insurance Card
Medical Assistance Card
Drug Prescription Card
Dental Insurance Card
Photo ID, such as driver’s license, State ID, passport or other government issued photo
Financial Power of Attorney or Guardianship Papers
Medical Power of Attorney and/or Living Will
Revocable or Irrevocable Trust Document (all pages) if applicable
Pre-paid Irrevocable Funeral Expenses with funeral home of your choice.
Required Financial Documentation as stated below: Most recent financial statements for all accounts/investments.