Residency Application

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Residency Application

Please complete the form below to submit your application for residency.

Please review the application carefully and complete all sections. Select the communities you would like to apply to:
- Ashley Woods at Penfield Square (Assisted Living - Penfield)
- Ashley Woods at Penfield Square (Memory Care - Penfield)
- Beatrice Place (Senior Apartments - Greece)
- Brentland Woods (Assisted Living - Henrietta)
- Episcopal Church Home (Skilled Nursing – Rochester)
- Pinehurst (Independent Living – Honeoye Falls)
- River Edge Manor (Independent Living – Rochester)
- Seabury Woods (Assisted Living - Gates)
- Seabury Woods (Memory Care - Gates)
- Seabury Woods (Patio Homes - Gates)
- The Center for Rehabilitation (Transitional Care - Rochester)
- Valley Manor (Custom Apartment Homes - Rochester)
Please review the application carefully and complete all sections. Select the communities you would like to apply to:
First Name*
Middle Initial
Last Name*
Address*
City*
Select State*
Zip*
Preferred Phone*
Alternative Phone
Religion
Have you or your spouse ever served in the United States military?
Place of Birth
Date of Birth
Social Security #
Email*
Have you been vaccinated for COVID-19?*
- Yes
- No
If yes, please provide dates of vaccinations: 1st dose
Dose 2
If not, would you like a COVID-19 vaccine at ESLC?**
- Yes
- No, I decline the vaccination.
Marital Status:
- Single
- Married
- Divorced
- Widowed
- Partner
United States Citizen:
- Yes
- No
*** If you were not born in the USA you will need to provide copies of your permanent visa/naturalization papers or green card. Thank you.
Naturalized Citizen (if not born in the USA only):
- Yes
- No
Permanent Residency Visa (if not born in USA only):
- Yes
- No
Date of Naturalization
*** If you were not born in the USA you will need to provide copies of your permanent visa/naturalization papers or green card. Thank you.
Year Residency Visa Obtained
Persons to Notify for Emergencies:
Emergency Contact #1
First Name*
Middle Initial
Last Name*
Address*
City*
State
Zip*
Preferred Phone*
Alternate Phone
Relationship
Emergency Contact #2
First Name*
Middle Initial
Last Name*
Address*
City*
Select State
Zip*
Preferred Phone*
Alternate Phone*
Relationship
Power of Attorney:
- Same as emergency contact #1 ?
First Name
Middle Initial
Last Name
Address
City
Select State
Zip
Preferred Phone
Alternate Phone
Relationship
Funeral Home Arrangements:
Funeral Home
Contact First (if known)
Contact Last (if known)
Address
City
Select State
Zip
Phone
Fax
Financial Information:
All applicants must complete this section.
Social Security*
Cash (checking & saving)*
Pension*
CDs, Money Market, etc*
Interest*
Stocks and Bonds*
Dividends*
IRAs, Annuities, etc*
Mortgage / Rental Income*
House*
IRA Income*
Other Real Estate*
Trust Income*
Life Insurance*
Other Monthly Income*
Trust Fund*
Total Monthly Income*
Other Assets*
Total Assets*
Liabilities:
Home Mortgage*
Loan/Installment Payments*
Car
Other Liabilities*
Total Liabilities*
Plans for Disposition of Home and Real Estate*
Does resident have a Durable Power of Attorney?
- Yes
- No
Trust Fund
- Revocable
- Irrevocable
Conservatorship/Legal Guardian?
- Yes
- No
When was Trust Fund Established ?
Pending Status of any of the above?
- Yes
- No
Please explain
Has there been a transfer of assets including but not limited to real estate in the past 60 months?**
- Yes
- No
Please explain and note date(s) of transfer(s)
Regular Monthly Expenses
Health Insurance **
Prescriptions **
Food **
Legal/POA/Financial **
Pet Expenses **
Car **
Other **
Total Amount **
Health Information
Name and Address of Primary Care Physician:
First Name
Middle Initial
Last Name
Address
City
Select State
Zip
Preferred Phone
Alternate Phone
Additional Medical Information:
Long Term Care Insurance:
Carrier
Number
Prescription Drug/Medicare Part D Insurance:
Carrier
Number
I hereby give permission to my physician to provide health care and medical information as applicable.
Physician's Name
Please list any other health care providers including their name, address and telephone number
Co-Resident
Is there a co-resident?
- Yes
- No
First Name
Middle Initial
Last Name
Address
City
State
Zip
Preferred Phone
Preferred Phone
Religion
Place of Birth
Date of Birth
Social Security #
Email
Have you been vaccinated for COVID-19?**
- Yes
- No
If yes, please provide dates of vaccinations:
Dose 2
If not, would you like a COVID-19 vaccine at ESLC?**
- Yes
- No, I decline the vaccination.
Please sign this application by typing your name below.
By signing below, you are hereby affirming that all of the above information is correct and truthful to the best of your ability. Your signature below grants your primary care physician permission to provide health care and medical information as applicable.
Applicant/Designated Representative Signature**
Date**
Co-Resident Signature (if applicable)
Date
Name
This field is for validation purposes and should be left unchanged.

In making admission decisions, Episcopal SeniorLife Communities does not discriminate on the basis of race, creed, color, national origin, handicap, gender, age, source of payment, marital status, or sexual preference.