APPLICATION FORM. Eligibility. Application Process

Transcription

1 APPLICATION FORM Eligibility 1. Applicants must be able to manage most or many daily tasks independently, arrange, manage and direct their own care and be responsible for decisions about day-to-day activities. 2. Applicants should be 65 years of age or older. Applicants under 65 years of age may qualify for some communities. 3. Must be a Canadian citizen or Permanent Resident (landed immigrant). Application Process 1. Complete all sections of the application form and sign where appropriate. 2. Provide a copy of your Notice of Assessment (processed Income Tax) from the most recent tax year as well as a copy of your Alberta Government Carbon Levy Rebate (ACLAR). If you cannot locate yours, call Canada Revenue Agency at Ask your doctor to fill out the Medical Report. Please note that if there is indication of memory loss, a memory test (MOCA or MMSE) will be required. 4. Submit the application form, NOA, Carbon Levy Rebate and Medical Report through fax: , mail: 804, 7015 Macleod Trail SW, Calgary, AB T2H 2K6, or placement@silvera.ca. 5. Once your application is received, our Placement Team will review the application and supporting documents to ensure they are complete. If information or documentation is missing, you will be notified. 6. Upon receipt of your completed application, a member of the Placement Team will contact you to schedule an in-person meeting to review your application. This discussion will assist in determining eligibility and options for housing. If eligible, your name will then be added to our waiting list. 7. When a suite becomes available, you will be called for an intake interview. Please note that your needs will be re-assessed at this time to ensure they can be met within the services we provide. 1

2 This confidential information is being collected under the authority of the Alberta Housing Act and will be used to determine eligibility of applicants, need and allocation within the housing programs at Silvera for Seniors. Collected personal information is protected from unauthorized access, collection, use and disclosure in accordance with Alberta privacy legislation and can be reviewed or corrected upon request. Questions regarding the collection of personal information can be directed to: APPLICANT CONTACT INFORMATION FOIP Coordinator Silvera for Seniors Phone: / Fax: / contact@silvera.ca Last Name: First Name: Middle Name: Also known as: Date of birth: Age: Current Address: City: Province: Postal Code: Phone #: CO-APPLICANT CONTACT INFORMATION Last Name: First Name: Middle Name: Also known as: Date of birth: Age: ***Please note that a separate application will need to be submitted for the co-applicant*** APPOINTEE INFORMATION (if applicable) Power of Attorney Enduring Power of Attorney ( enacted / acted) Legal Guardian Public Trustee Personal Directive If you check any of the boxes above, we may need to discuss the nature of the relationship and have supporting documentation provided. CITIZENSHIP & MIGRANT STATUS What is your current citizenship and immigration status? Canadian citizen 2

3 Permanent Resident (Landed immigrant) Other: How long have you been in Canada? How long have you been in Calgary? years years GENERAL INFORMATION What is your primary language? English French Other Is an interpreter required? Yes No If yes, do you have access to an interpreter? Yes No Why do you want to move to Silvera? Affordable Housing 24/7 non-medical staff Recreational Activities (please list any special interest): Housekeeping Services Meals Other (please specify): How did you learn about Silvera for Seniors? What is the reason you are considering housing with Silvera? Have you ever lived at Silvera before? Yes No If yes, please list reason(s) for leaving: Have you ever used a housing supports program? Yes No If yes, please list it: INCOME (please check all that apply) Annual Income from Line 150 of most recent NOA $ Please attach copies of both your most recent Notice of Assessment and proof of your Carbon Levy Rebate (ACLAR) from Canada Revenue Agency 3

4 AISH $ Old Age Security $ Alberta Seniors Benefits $ Guaranteed Income Supplement $ Carbon Levy Rebate (ACLAR) $ Canada Pension Plan $ Other Pension $ Employed $ Other( e.g.: Rental, RSP, RIF, etc): $ ASSETS Property $ Land: $ Car: $ Investments: $ Savings: $ Other: $ Do you require a parking space? Yes No CURRENT LIVING SITUATION Own house Rented Shelter Transitional Housing Hospital Treatment facility Long Term Care Facility Staying with friends Staying with family Other: Is there any length of stay deadline in your current living situation? Yes No If yes, what is the date your living situation will end? ***Please provide supportive documentation if applicable*** How much do you pay for your current rent/mortgage? $ per month Landlord s name: Phone #: Permission to contact or discuss your information: Yes No Signature of Applicant SUPPORTS REQUIRED (please use an X to describe yourself in the following areas) Meals Task / Assistance Required No Assistance Some Assistance Full Assistance Comments Housekeeping Laundry 4

5 Bathing Finances Personal shopping Arranging transportation Dressing Walking Making appointments Managing hearing aid Managing stairs Accessing help Evacuating a building Managing electronics (phone, TV remote, etc.) MEDICAL INFORMATION Do you have a Alberta Health Care number? Yes No Do you have a physical health condition? Yes No If yes, please provide further information: ***Number not required*** Do you have incontinence? Yes No If yes, do you use incontinence products? Yes No Have you had any falls in the past year? Yes No If yes, please provide further details: Do you require a mobility aid? Yes No If yes, please list: Do you require specialized housing accommodations due to a disability? Yes No If yes, please explain: Do you have memory loss? Yes No ***If yes, please provide copy of a recent memory test completed by a medical professional*** 5

6 Have you ever had any confusion concerns? Yes No If yes, please provide further details: Are you taking medications at the present time? Yes No Do you require assistance/reminders to administer your medication(s)? Yes No N/A Do you access home care? Yes No If yes, please provide further information (what kind of supports, how often, etc.): Do you have any severe allergies? Yes No If yes, please list it: Do you require a special diet? Yes No N/A If yes, please list it: Are you on oxygen? Yes No Do you smoke? Yes No ***Please note that all Silvera buildings are smoke-free*** Do you have a mental health condition? Yes No If yes, what are the symptoms and what are your coping strategies? HOUSING OPTIONS - Please list below the communities you would prefer to be considered for. Please note we may explore other options based on availability as well as your needs. Check our website at

7 If someone is helping you with this application, please complete this section Option 1 (If applicable) Name: Relationship: Current Address: Phone #: Permission to contact or discuss your information: Yes No Signature of Applicant: ***If this section is not signed by the applicant, we will not discuss the application with you*** Option 2 (If applicable) Name: Relationship: Current Address: Phone #: Permission to contact or discuss your information: Yes No Signature of Applicant: ***If this section is not signed by the applicant, we will not discuss the application with you*** APPLICANT'S ACKNOWLEDGEMENT I understand and agree that this application is neither a contract nor a reservation for residence. Nothing contained in this document obligates or entitles me to a suite at Silvera for Seniors until a Tenancy Agreement has been signed by all parties involved. Signature of Applicant: Date of Application: 7