Resident Application Step 1 of 2 50% Resident / Responsible Party InformationCompleted by the resident or responsible partyResident Legal Name(Required) First Last Phone(Required)EmailDate Of Birth(Required) Month Day Year Age(Required)This field is hidden when viewing the formSection BreakResponsible Party Name(Required) First Last Responsible Party Relation(Required)Also Power of Attorney? Yes Phone(Required)Email(Required) Is the Responsible party signing also completing the application?(Required) Yes No Resident Primary MD Name First Last MD PhoneThis field is hidden when viewing the formSection BreakDetailed Information(Completed by resident / responsible party)Were you referred by a current Grace resident / Family or Agency?(Required) Yes No Name of Referral AgencyName of Resident / Family who referredIs the Resident bringing a pet?(Required)Note: Pet Fee – $1,500 Yes No Where is the resident admitting from?(Required)Is the resident admitting on home health or hospice services?(Required) Yes No Name of Home Health or Hospice Agency(Required)Does the resident have a history of aggressive, violent or sexually inappropriate behavior?(Required) Yes No Please Explain(Required)Is the resident currently utilizing Medicaid or planning on using Medicaid financing?(Required) Yes No Date of Planned Use(Required) Month Day Year Power Of Attorney InformationName(Required)Phone(Required)Name of Person Completing the Application(Required)Digital Signature(Required) I acknowledge that the above information is accurate and that I am providing Grace with a deposit of $1500 (either by check or credit card) to reserve my apartment. I realize that when the resident occupies the apartment this amount becomes non-refundable. Initial(Required)Date(Required) Month Day Year Community InformationCompleted by Grace StaffGrace Community Location(Required)Boise – EnglefieldBoise / Eagle – Independent and AssistedBoise / Eagle – Memory CareCaldwellChubbuck / PocatelloFruitlandMeridianNampaTwin FallsName of Touring Employee(Required)Apartment Number(Required)Apartment SizeAL – StudioAL – Large StudioAL – 1 BedroomAL – Deluxe 1 BedroomAL – 2 BedroomAL – Friendship SuiteMC – SharedMC – StudioMC – DeluxeFileMax. file size: 256 MB.EmailThis field is for validation purposes and should be left unchanged. Δ