Chat with your loved one via Skype Like Us on Facebook Follow Us on Twitter

Application for Residency

All information will be held confidential.

Application for Residency - PDF version

Resident #1



Address










Resident #2



Address









Alternate Address





Power of Attorney (if applicable) Resident #1

Address




Telephone Numbers:




Power of Attorney (if applicable) Resident #2

Address




Telephone Numbers:




Person to notify in case of emergency


Address




Telephone Numbers:



Please provide name of primary physician - Resident #1


Address




*Advanced Directives

Please provide name of primary physician - Resident #2


Address




*Advanced Directives

Health Condition - Please describe any major changes in your general health in the past year and any chronic illnesses or diseases.




Resident #1




Resident #2





Applicant's Financial InformationBethany Village is a not for profit corporation that recognizes its profound responsibility to provide a resident centered environment and service continuum. As such, it must rely on a similar commitment from residents to fully reimburse Bethany Village for its services. Please complete the financial application form below. It will be held in confidence and not released to any person, agency or party unless directed by the resident.
Regular Monthly IncomeResident #1Resident #2Joint
Social Security

Pension

Dividends/Interest

Mortgage/Rental Income

IRA Income

Trust Income

Other Monthly Income

Total Regular Monthly Income

Assets   
Cash (Savings & Checking)

CD's, Money Market, etc.

Stocks, Bonds, Mutual Funds

IRA's, Annuities

Real Estate

Real Estate - existing mortgage or lien?
Other Assets/Burial Fund

Total Assets Listed

Regular Monthly Expenses   
Prescription Drugs

Are medications covered by health insurance?
Health Insurance

Loans, Credit Cards, Other Debts

Total Expenses Listed


The financial information on this form is a true and correct statement of my financial position to the best of my knowledge and belief. I further attest that I have not transferred, or donated to other persons assets not reflected on this form within the past three years and will not transfer or donate assets to other persons in the future which would preclude my ability to meet my financial obligations to Bethany Village. If assets have been transferred, please provide a list including approximate dates of transfer. I am able to accept this financial obligation.






Family Member Contacts - Please list in the order that you want us to call























































Please enter the following



Bethany Village, in compliance with New York State and Federal laws which prohibit discrimination based on race, creed, color, national origin, age, sex, marital status, sexual preference, disability, blindness, source of payment or sponsorship, this facility admits and treats all residents on a non-discriminatory basis.