Application Form

Application for Admission

Rose Valley Manor is a senior's enriched housing facility requiring residents to be level 1 or 2 care.

Potential resident:

Is able to live compatibly in a small group setting
Ambulates independently or with limited assistance (may use can, walker or wheelchair)
Comes to dining room for meals
Takes own medications, with or without assistance from support staff
Independent use of bathroom
Performs own daily care and dresses with the assistance of home health aide if required

We encourage individuals and families to arrange for a tour prior to sending in their application.

Personal Information
Name in Full:
Sex:
Address:
City/Town:
Province:
Postal Code:
Date of Birth:
Marital Status:
Name of Spouse:
Address:
City/Town:
Province:
Postal Code:
Care & Responsibilities
Emergency Contact
Name of responsible person who can act on your behalf in emergency:
Address:
City/Town:
Province:
Postal Code:
Relationship:
Phone Number:
Medical Information
Name of Doctor:
Address:
Town/City:
Province:
Postal Code:
Phone Number:
Saskatchewan Health Service Number:
Other Health Company:
Other Health Company Number:

I hereby declare that I have completed this application form to the best of my knowledge. If accepted I will abide by the rules and regulations as set by the board of directors or management. I also recognize that the board of directors will not be responsible in any way for any debts which I may incur. Your printed name constitutes your signature: