Seniors' Independent Living Application

The Cridge Village Seniors Centre offers 2 meals per day, housekeeping services, recreation programming, and 24-hour security for senior citizens capable of independent living.

This is a smoke-free facility – smoking is not permitted anywhere on the property, inside or out. Unfortunately, we are unable to accommodate pets.

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.

Name of an Applicant(Required)

First Last

Date of Birth(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of an Applicant #2 (if applicable)

First Last

Date of Birth for Applicant #2

Phone

Requested Occupancy Date

Accommodation required

One bedroom

Two bedrooms

Vehicle Parking required

Yes

Number of parking spots required

Emergency Contacts

Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone Number

Secondary Phone Number

Family Physician Info

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Current or Former Occupation

Current or Former Occupation - Applicant #2

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

Gross Monthly Income

Describe your current living arrangements (e.g.: own home, condo, renting, other facility, living with family):

Do you currently have Home Support assistance? With what?

Other comments you feel may be important:

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