APPLICATION FOR ACCOMMODATION

APPLICATION FOR ACCOMMODATION
Thank you for applying for residency at Shalem! Caring effectively for older adults is at the heart of Shalem’s vision and mission and we look forward to further connecting with you on becoming a part of the Shalem community!

Please complete the application form below to provide us with the necessary information to determine the most suitable housing option for you at Shalem. Please note that an application form must be completed for each individual seeking residency at Shalem.
Please indicate which building(s) you are seeking residency. Check all that apply.

The Haven at Shalem - Licensed Supportive LivingThe Manor at Shalem - Independent Subsidized Housing*The Court at Shalem - Independent Life Lease Suites
*All applicants for the Manor are required to email last year’s Tax Assessment and a List of Current Assets to living@shalem.ca in order to be placed on the Waiting List.
Full Legal Name
Date of Application

MonthDayYear
Are you applying for residency just for your self?

YesNo
If No, please provide the name of your spouse/ co-applicant below.
Name of alternate contact person.
Phone number of alternate contact person.
Home Phone
Cell Phone
Email
Street Address
City
Province
Postal Code
Date of Birth

MonthDayYear
Country of Birth
Gender
Primary Language
Secondary Language
Marital Status

WidowedMarriedSingleDivorcedOther
Church Affiliation (If Applicable)
How did you hear about Shalem?

Family & FriendsChurchFacebookAdvertisingHealthcare ProfessionalSenior Support ServicesOther
What is your current living situation?

Living IndependentlyLiving With FamilyLiving in Another Seniors Community FacilityLiving in Transitional Care (Due To Recovery or Health Condition)Other
If living independently, do you rent your home or own?

RentOwn
How long have you been living in your current living situation?
Do you live alone?

YesNo
Do you currently own a pet?

YesNo
Do you own a vehicle?

YesNo
Do you drive yourself regularly?

YesNo
What is the reason you are applying to move into senior housing?
What is it about Shalem that appeals to you?
When are you looking to move?
How do you currently enjoy spending your time?
Please select any hobbies or interests.

ReadingGames & PuzzlesMusicChurchArts & CraftsTravelSocializingVolunteeringCookingExercise ClassesDancingBird WatchingGardeningComputersWoodworkWalkingHikingMoviesOther

Please indicate the extent of assistance you are receiving in the following areas:

	I do this myself	I receive some assistance	Someone does this for me
Housekeeping
Laundry
Preparing Meals
Eating
Bathing
Dressing
Shopping
Finances
Driving

Are you on a special diet or do you need assistance with eating?

YesNo
If yes, please explain.
Do you smoke?

YesNo
If you have previously smoked, how long has it been since you quit?
Do you have any gastrointestinal concerns?

YesNo
If yes, please explain.
Have you been diagnosed with any of the following? If none, please select none.

DepressionAnxietyParanoiaSchizophreniaBipolar DisorderAddiction to AlcoholAddiction to drugsAttempted SuicideNone
Do you have any chronic diseases which may require specialized care?

YesNo
If yes, please explain.
Have you been hospitalized for a chronic condition in the past six months?

YesNo
If yes, please explain.
Do you require any mobility aids for daily living?

YesNo
If yes, please indicate which aids you currently use.

CaneWalkerWheelchairScooterOther
Are you, currently, receiving Home Care or other support services?

YesNo
If yes, please explain what support you currently receive.

How does the following affect your ability to function?

	No Affect	Some Affect	Major Affect
Hearing
Vision
Perception
Thinking
Memory-Making; Judgement
Physical Dexterity
Balance
Strength
Energy
Bowel Control/ Incontinence
Physical Impairment
Depression
Arthritis
Hypertension
Heart Disease
Diabetes
Speech

Any additional comments for this application if required.
I acknowledge that the information in this application is true to the best of my knowledge and is submitted in consideration for residency at Shalem Society for Senior Citizens Care.
Today's Date

MonthDayYear
Printed Name
Signature

Clear
Thank you for your interest in living at Shalem!

Please complete and click submit to send in your application.

If you have any questions please contact our Resident Life Administrator at living@shalem.ca or 403-240-2800 Ext.2

All shared information is kept private and confidential.
#101, 3010 - 51st Street SW | Calgary, Alberta | T3E 6V8

403.240.2800 | www.shalem.ca
Should be Empty: