Size: A A A	Login

Home > Contact & Admissions > Apply Online

Apply Online

This application is not for employment. For employment opportunities and applications, click here.

Section One - Applicant 1 - Personal Information *denotes required field
Which community are you applying for?*
Name(Last)*
(First)*
(MI)*
Street*
City*
State*
Zip*
County*
Telephone*	(e.g., 123-456-7890)

Marital Status	Married Never Married Widowed Divorced Separated

Applicant is currently at	Home Personal Car/Asst. Living Other Nursing Home Hospital

Birthdate*

Sex	Male Female
SSN
Religious Affiliation
Church/Temple
Ambulance Membership/Affiliation/ Preference
Contact Persons
Name*
Address*
Relationship
(E-mail)*
(Home)* (Work) (Cell)
Name
Address
Relationship
(E-mail)
(Home) (Work) (Cell)

What type of Power of Attorney do you have?	Financial Medical Durable None
Name Address Phone

Anticipated length of stay	Short Term Long Term Undecided

Section Two Health Insurance/ Prescription Coverage

Medicare	A (Medicare A Number) B (Medicare B Number)
HMO	(HMO Number)

Secondary/ Other Insurance	(Name of Insurance) (Insurance Number)

Long Term Care Insurance	(Name of Insurance) (Insurance Number)

Section Three - Financial Information

Do you own your own home?	Yes No
House Value

Do you currently have a mortgage on your home?	Yes No

Monthly Income	(Pension) (Social Security) (Annuity)

Other (please list)	(Name) (Amount)

Other (please list)	(Name) (Amount)

Other (please list)	(Name) (Amount)
Total monthly income from all sources
Estimated total assests, excluding home

Have you transferred any real estate, personal property, money, stocks, bond, mortagages or anything else of value during the last three years?	Yes No
Name of Person Transferred to Date of Transfer Amount of Transfer
Name of Person Transferred to Date of Transfer Amount of Transfer
How did you hear about Phoebe Ministries?	Friend/Relative Church Community Resident of Phoebe Newspaper Other Internet
I understand that any misrepresentation or omission of information on this application will disqualify me from consideration of possible admission to the facility indicated and will be cause for discharge if discovered after my admission. I certify that the information contained within this application is true and accurate to the best of my knowledge. Note: Compliance is denoted through electronic submission.
Name of Applicant*
Name of Person Completing Application*
Date*

To print and mail a hard copy of our admissions application, please click here. You will need the FREE Adobe Acrobat Reader to view the form.

	Events Calendar Get detailed information on upcoming events.

	eNewsletter Sign up today and receive up-to-date information about Phoebe.

	Send a Message of Cheer! Send a free e-card to one of our residents.


	Apply Online Fill out an application for our services or for residency.

	Questions? Inquire about our services using our easy online form.

Phoebe does not discriminate in admissions, the provision of services, or referrals of clients on the basis of race, color, religious creed, disability, marital status, ancestry, national origin, sexual orientation, age, or gender.