Seniors' Independent Living Application

This application must be completed by the applicant(s) and not by a representative. Should the applicant(s) be unable to complete this form on their own, please describe the reason in the Other Comments section.

If the potential resident is unable to complete the application due to computer unfamiliarity, to please print off the form and complete it by hand.

Please note an application does not secure residency; there is an interview and selection process.

First Name of Applicant

Last Name

Co-Applicant First Name (if applicable)

Co-Applicant Last Name (if applicable)

Date of Birth

Co-Applicant Date of Birth (if applicable)

Phone

Address

Address Line 2

City

Province

Postal Code

Requested Occupancy Date

Accommodation Required

One-bedroom (standard) One-bedroom (heritage) Two-bedroom (heritage)

Is vehicle parking required?

Emergency Contact First Name

Emergency Contact Last Name

Relationship

Primary Phone Number

Secondary Phone Number

Address

Address Line 2

City

Province

Postal Code

Family Physician First Name

Family Physician Last Name

Primary Phone Number

Address

Address Line 2

City

Province

Postal Code

Applicant Occupation

Co-Applicant Occupation

Gross Monthly Income

Describe your current living arrangements

Describe any mobility aid(s) that you use (eg: walker, scooter):

Do you currently have Home Support assistance? With what?

Any further comments?

Seniors' Independent Living Application

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Seniors' Independent Living Application

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