SCNC Application for Residency

Page 1 of 3       To apply for admission to St. Catherine's Nursing Center, please complete the following online application. This application will become a part of the "Resident Agreement" and should be completed in its entirety. All information submitted is confidential. Please note: St. Catherine's Nursing Center is a smoke-free campus.         GENERAL INFORMATION       1. Date of Application:*         2. Prospective Resident:*   Name   Gender:   Age:   Date of Birth:   Social Security Number:   Street Address:   City:   State:   Zip Code:         3. Spouse Information   Name:   Telephone Number:   Street Address:   City:   State:   Zip Code:         4. Marital Status*   Single   Married   Widowed   Divorced       5. Faith   Religion:   Name of Clergy:         6. Country of Citizenship*         7. Were you in the Armed Forces?   Yes No       8. Occupation Before Retirement         9. Education - Years Completed   Did not finish high school   High School   College/University   Graduate School   Other, please specify               10. Primary Language*         11. Skilled Nursing Facility   Name:   Admission Date:   Discharge Date:   Facility Street Address:   City:   State:   Zip Code:         12. Current Physician   Name:   Phone Number:   Street Address:   City:   State:   Zip Code:         13. Current Dentist   Name:   Phone Number:   Street Address:   City:   State:   Zip Code:         14. Medicare A copy of the card is required.   Medicare Number:   Part A:   Part B:         15. Does Prospective Resident Have Any Other Health or Long Term Care Insurance?*   Yes No       16. If yes, please provide the following information: A copy of the card is required.   Name of Insurance Company:   Policy Number:         17. If Prospective Resident has Pre-Paid Burial Plans, please provide:   Name   Street Address   City   State   Zip Code         18. Was Prospective Resident Admitted to the Hospital During the Last 30 Days?*   Yes No       19. If yes to hospital admission, please provide:   Date of Admission:   Date of Discharge:   Name of Facility:   Telephone Number:   Diagnosis:         20. If resident is unable to make finanaical/medical decisions, who is responsible?*   Name:   Relationship:   Street Address/P.O. Box:   City:   State:   Zip Code:   Home Telephone Number:   Work Telephone Number:         21. Additional Relatives/Significant Others   Name:   Relationship:   Home Telephone Number:   Work Telephone Number:         22. Additional Relatives/Significant Others   Name:   Relationship:   Home Telephone Number:   Work Telephone Number: