Senior Lodge Application - Ridge Country Housing

Application for Admittance to Senior Citizen's Lodge

Last Name: Given Name:

Address: Telephone:

Address:

Date of Birth Day: Month: Year: Social Insurance #:

Alberta Health Care #:

Marital Status: Married Single Widow(er) Divorced

Years of Residency in our Area: County of Warner: Alberta:

Family Doctor First Name: Surname:

Address:

Telephone: Hospital Name:

Emergency Contact First Name: Surname:

(a local person who can be Address:

called if & when required) Telephone: Relationship:

Family Members First Name: Surname:

Address:

Telephone: Relationship:

First Name: Surname:

Address:

Telephone: Relationship:

First Name: Surname:

Address:

Telephone: Relationship:

Enduring Power of First Name: Surname:

Attorney Address:

(if applicable) Telephone: Relationship: