SENIOR CITIZEN ACCOMMODATION APPLICATION

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Cuthbert Hancock
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BOX 790, FORT MACLEOD, AB, T0L 0Z0 TEL: 403-553-3662 SENIOR CITIZEN ACCOMMODATION APPLICATION Accommodations Requested for: Colonel Macleod Manor Chinook Arch Manor (Granum) Complete all questions

A copy of your most recent Income Tax Return and/or Notice of Assessment 2. Medical form Your application must be signed and witnessed. You will be contacted for an interview/needs review.

1 BOX 790, FORT MACLEOD, AB, T0L 0Z0 TEL: SENIOR CITIZEN ACCOMMODATION APPLICATION Accommodations Requested for: Colonel Macleod Manor Chinook Arch Manor (Granum) Complete all questions and all of the requested information. If a question does not apply to your situation mark N/A in the section. You are requested to provide: 1. A copy of your most recent Income Tax Return and/or Notice of Assessment 2. Medical form Your application must be signed and witnessed. You will be contacted for an interview/needs review. *All information collected under the authority of the Alberta Housting Act and is in accordance with Alberta's Freedom of Information and Protection of Privacy Act. This information will be used to determine and verify the client's elegibility under Social Housing Accommodation Regulations. If you have any questions you may contact Jackie Vanee-Palmer at (403)

2 Macleod Pioneer Lodge Chinook Arch Manor Colonel Macleod Manors 1 and 2 1. Name: Social Insurance Number: Birth date: Telephone #: 2. Spouse/Co-applicant Name: Social Insurance Number: Birth date: Telephone #: 3. Marital Status: Married Divorced Widowed Single Common-Law Separated 4. Present Address: Owned Rented Type of Dwelling: Length of Tenancy: Rental Payments: (if applicable) Landlord s Name: Landlord's Telephone Number: Total # if bedrooms: Number of Bathrooms:

3 Do rental payments include: Heat Yes No Electricity Yes No Water Yes No Is the dwelling shared with another family? Yes No 5. Are you a: Canadian Citizen Landed Immigrant Other 6. Emergency Contact: Relationship: Address: Telephone: 7. Family Doctor Name: Telephone: 8. Do you have a pet? Yes No What kind? Are you willing to part with your pet(s)? Animals are NOT permitted 9. Is there any medical condition that could affect your housing needs that we should know about? Yes No (for example, wheelchair/walker required) 10. Why do you wish to move? 11. When are you prepared to move 12. Have you ever lived in a building that had bed bugs? Yes No

4 13. Assets: Real Estate Value: $ Mortgage: $ Investments: $ RRSP/RRIF $ Vehicle: Value: $ Year/Make/Model: Other: Value: $ 14. References (not relatives): Name: Telephone: Name: Telephone: 15. Income: Type of Income Tenant Co-Tenant Old Age Pension & Supplement Canadian Pension War Veterans Pension Alberta Seniors Benefit Social Assistance Disability Pension Employment Insurance Bene fits Worker s Compensation Company Pension/Superannuation Employment Income A.I.S.H. Income Derived from Assets Other Income (please specify)

5 16. If you or your Co-Applicant have employment income(s), please state the name(s) and address of the employer(s): Applicant Employer: Co-Applicant s Employer: I understand that this application does not constitute an agreement on the part of Willow Creek Foundation or its agents to provide me with rental accommodations. I further acknowledge the right of the Foundation at any time prior to the execution and delivery of a lease hereby applies for, to withdraw, revoke or cancel without penalty or liability for damage or otherwise, any acceptance or approval of this application previously made or given. I hereby authorize the Foundation to make any inquires deemed necessary to verify the facts contained herein by the method the Foundation deems necessary, being fully aware that discovery of any false statement shall cancel further consideration of any application. I further agree that I am obligated to advise the Foundation, in writing, of any changes in family composition, gross income, assets, employment or change of address, should they occur. Applicant: Co-Applicant: Witness:

6 DECLARATION I/We of the city/town of in the Province of Alberta, do declare as follows: 1. That I/We am/are the applicant(s) named in the said application; 2. That any statements made by me/us in the said application are to be the best of my/or knowledge, information and belief, full and true in all respects: 3. That I/We have resided in the province of Alberta for years of my/our life and in the district of Willow Creek for years. And I/we make this Declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath. Declared before me at the of in the Province of Alberta this day of, 20 Willow Creek Foundation Signature of Applicant Signature of Co-Applicant Freedom of Information and Protection of Privacy Act (FOIP) Consent and Noti fication Form The Freedom of Information and Protection of Privacy Act (FOIP) requires that informed consent be obtained for the collection, use and disclosure of all personal information that is not authorized under the Alberta Housing Act. This includes many activities that occur regularly in lodges/apartments, such as the use of individual and group photos, the listing of names for scheduled activities, and

7 the use of names and pictures in newsletters, annual reports and other public documents. It is the intent that the Act should be applied in a common sense manner and should not negatively affect a person s life. The purpose of this notice is to inform you about the collection, use and disclosure of your personal information by the Administration and Management of Willow Creek Foundation. Willow Creek Foundation requires your consent for the following: 1. The use of my name, photos and comments in activity calendars, newsletters, or other Willow Creek Foundation publications. 2. The taking of individual or group photos and the use of my photo for display purposes inside the senior s facility. 3. The use of my name or artwork or other material displayed at Willow Creek Foundation sponsored displays in the community. 4. The taking of photos and/or videos of me participating in activities where the material will be used by Willow Creek Foundation. 5. The use of my name in listing and/or announcements of awards, activities where the material will be used by Willow Creek Foundation. 6. The use and display of my name on my room door. 7. The listing of my name and room number on the directory board inside the building. 8. The listing of my name on the entry security system (if applicable). 9. The posting of my name on signup sheets for service providers, bus trips, meal attendance or absence.

8 10. The taking of photos and/or videos of me and their use, by the media, and other organizations where I am not interviewed or identi fied by name. 11. The disclosure of information concerning my health and social needs to health care professionals and my named responsible party and/or legal guardian. I consent to the above: Applicant Signature: Date: Witness Signature: Date:

C O N F I D E N T I A L

APPLICATION FOR HOUSING PROGRAMS (Excluding Supportive Living / Lodge Accommodation) C O N F I D E N T I A L This application form is to be completed by anyone who is applying for any or all of the following