Independent Living Residential Application

Independent Living Rental Application for Clearview Home (65+)

Todays Date*

Date

Date you would like move into a Studio at Clearview Home*

Date

Applicants Full Name*

Preferred Name*

Street Address*

Phone*

City*

State*

Zip*

Email Address*

example@example.com

Date of Birth - must be 65+*

Date

Christian Science & Background Information:

Are you a member of The Mother Church*

A branch church / or society*

If not a member how long have you been studying Christian Science

Do you rely on Christian Science treatment for healthcare needs?*

Do you receive support from a Christian Science practitioner? (Optional)

Are you able to live independently and manage your daily activities? (Yes/No) If no please briefly explain: *

Health & Mobility Information:

Do you currently use any mobility assistance (walker, cane, wheelchair, etc.)? If yes, please describe: *

Do you have any accessibility needs within your living space? If yes, please describe: *

Financial Information:

Do you have the financial means to meet rental obligations monthly? You will fill out a separate financial form. (Yes/No)*

What is your preferred payment method (Check / Bank Transfer / Other)*

Christian Science References

Please provide two references who can speak to your practice of Christian Science.

1. Name*

First NameLast Name

Relationship:*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

2. Name*

First NameLast Name

Relationship:*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Additional Information: Why are you interested in Independent Living at Clearview Home? Is there anything else you'd like us to know?

AUTHORIZATION for Background and Credit Check

By signing below, I authorize Clearview Home to conduct a background and credit check as part of the application review process. I understand this information will be used solely to assess eligibility for Independent Living Residency.

ACKNOWLEDGMENT

By signing below, I affirm that the above information is accurate to the best of my knowledge, and I understand Clearview Home is a Christian Science facility committed to supporting spiritual healing.

Signature of the Applicant*

Date*

Date

Clearview Home 935 Main Street Delafield, WI 53018 262-646-3361

www.clearviewhome.org ExecutiveDir@clearviewhome.org