SENIOR APPLICATION
Senior Sponsorship Program
Request for assistance through the Sponsor a Senior Program
We appreciate your interest. This application helps us understand what support may be helpful. Applying does not guarantee services or sponsorship. We will contact you to discuss needs, availability, and possible funding.
SENIOR INFORMATION
Full name:
First Name
Last Name
Preferred name:
First Name
Last Name
Date of birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email (if available):
example@example.com
Preferred contact method / best time to call:
Person completing this form (if different):
First Name
Last Name
Relationship to senior:
Legal representative / decision-maker (if applicable):
First Name
Last Name
Representative phone and email:
WHAT SUPPORT WOULD BE HELPFUL?
WHAT SUPPORT WOULD BE HELPFUL?
In-Home Support
In-Home Independent Living Support
In-Home Assisted Living Support
Fall-prevention / Home-safety assessment
Mobility / Safe Meddical Equipment - use support
Transportation
Clinical Liaison - Care coordination / Advocacy
Home Maintenance
Home Modification
Other
Please describe the help you are looking for and what matters most to you:
CURRENT SUPPORT AND SCHEDULING
Do you currently receive help at home? If yes, from whom:
Are you receiving home health nursing, OT, or PT? (optional):
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Days / times support would be most helpful:
Home access, communication, or scheduling considerations:
FINANCIAL ASSISTANCE REQUEST
Are you seeking full or partial sponsorship?
What amount, if any, could you contribute toward services each month? $
Is there a family member, organization, or other potential sponsor we may contact with your written permission?
CONSENT TO CONTACT AND ACKNOWLEDGMENT
I authorize Wellness at Home to contact me about this application and discuss potential services and sponsorship options. I understand that this application is not an agreement to provide services, does not guarantee funding, and does not replace a service agreement or separate privacy authorization. Wellness at Home will seek appropriate written permission before sharing my information with a prospective sponsor or other outside party, except as otherwise permitted or required by law.
Senior / applicant signature:
Printed name:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorized representative signature (if applicable):
Relationship / authority:
To discuss submitting this application securely:
Call or text 941-202-4005. Please do not email sensitive medical records with this form.
Wellness at Home Senior Concierge Specialists
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