Online Admission Application

Step 1 of 4

Name

This field is for validation purposes and should be left unchanged.

Personal Information

Name

First Last

Address

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

Phone

How did you learn of Sunrise?

Level of Care

Birthdate

Age

Gender

Birthplace

Education

Were you a Veteran?

Marital Status

Marriage Date

Spouse's Name

Lifetime Occupation

Present Living Arrangement

Church

Name of Church Affiliation

Church Address

Street Address Address Line 2 City State ZIP Code

Church Phone

Pastor's Name

Doctor

Do you have Advanced Directives

Doctor's Name

Doctor's Address

Street Address Address Line 2 City State ZIP Code

Doctor's Phone

Known Allergies

Dentist

Ophthalmologist

Pharmacy

Hospital Preference

Ambulance

Funeral Home

Funeral Home Name

Funeral Home Address

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

Funeral Home Phone

Additional Information

Do you have a Living Will?

Do you have a Power of Attorney for finances?

Financial Power of Attorney Name

Financial Power of Attorney Address

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

Do you have a Durable Power of Attorney for health care decisions?

Durable Power of Attorney Name

Durable Power of Attorney Address

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

Do you have a Legal Guardian?

Legal Guardian Name

Legal Guardian Address

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

Do you have a Conservator?

Conservator Name

Conservator Address

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

Please list children/relatives to contact (name, relationship, address, phone)

Confidential Financial Information

My current Monthly Income is

Please include any monthly Social Security, Pensions and/or Annuities, Rents, Interest, Dividends, & any other income received.

Estimate your ongoing monthly expenses (in dollars)

Example: credit cards, car payments, insurance, entertainment, etc.

Net Assets Total

Please include any Real Estate, Bank/Investment Accounts, Stocks, Bonds, or any other property that you own. Subtract any debt that is owed.

Do you have any Long Term Care Insurance coverage?

Do you have a pre-paid burial contract in place?

Have you (or your spouse) created a trust within the last 5 years?

Have you given or deeded away property or assets during the past 5 years?

According to my best knowledge and belief, the foregoing information is complete, accurate, and true. At the request of Sunrise Retirement, I am willing to furnish any further information necessary during the processing of this application. If admitted, I hereby agree to abide by and comply with all of the guidelines, rules, and regulations of Sunrise Retirement Community as are now in force or adopted.

Applicant Signature(Required)

Please type your full name below to serve as your electronic signature, confirming your agreement with the statement above.

Today's Date(Required)

Applicant's Address

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

Careers

Online Admission Application

Personal Information

Church

Doctor

Funeral Home

Additional Information

Confidential Financial Information

Sunrise Retirement Community

Living Options

Helpful Links

Careers

Online Admission Application

Personal Information

Church

Doctor

Funeral Home

Additional Information

Confidential Financial Information

Sunrise Retirement Community

Living Options

Helpful Links

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