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
NC-MS
Rehab Stay
Hold
Signature
Date
Denied