Application for Residency

Name: Care Cottages
Address: 11528 – 9th Avenue NW, Edmonton, Alberta, T6J 6T9, CA
Telephone: 780-996-9463

Apply For Residency

Dear Resident,

Thank you for your interest in Community Care Cottages Inc. We are the premier, boutique provider of fine supportive living homes for seniors in Alberta. In order to assess your suitability for residency in one of our homes, we ask potential residents to complete an Application for Residency.

This form is designed to help us begin to better understand you, your care needs and your preferences. We realize that many of the questions are of a personal nature. Your information will be regarded as privileged communication and will be treated with confidence, in accordance with all applicable legislation. Please ensure the information provided is complete and accurate so that we may make an informed decision about our ability to provide you with safe and quality care.

We look forward to reviewing your information and will be in contact with you to discuss our service philosophy and your application.

Kind regards,
Community Care Cottages Inc.

Online Application

Location
Resident's Name
First Last
Date of Birth*
Month
Day
Year
Gender
- Female
- Male
Marital Status
- Married
- Widowed
- Divorced
- Single
- Other
Former Occupation
Medical Information
Alberta Health Care Number
Name of Current Family Doctor
First Last
Doctor's Phone Number
Do you regularly visit any specialist physicians? If so, please list them.
Please list any important medical conditions / diagnosis
Please list any important medical conditions / diagnosis
Current Medication
Current Living Situation
Please describe your loved one's current living situation
Hobbies / Special Interests
Food and Nutrition
Does your loved one have any food or drug allergies?
Please, list them if this applies
Does your loved one require a special or restricted diet?
Please, explain if this applies
Family Contact Information
1st Next of Kin*
First Last
Relationsip to the Resident
- Daughter
- Son
- Husband
- Wife
- Sister
- Brother
- Granddaugher
- Grandson
- Significant Other
- Other
Phone (mobile)
Phone (home)
Phone (work)
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
This field is for validation purposes and should be left unchanged.