Bethel Lutheran Nursing and Rehabilitation Center Assisted Living Form
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Assisted Living Online Application

Thank you for you interest in Bethel Assisted Living Center. By completing this application, you are confirming your interest in an apartment in our Assisted Living Center. This information will be held in strictest confidence. Click the submit button when you have completed the application and we will contact you as soon as possible.
I. GENERAL
* 1. Name:
2. Name:
* Current Home Address:
* City:
* State:
* Zip:
* Home Phone:
Cell Phone:
Email:
* Birth Date: 1.     * Age:
Birth Date: 2.     Age:
II. CONTACT PERSON(CHILD OR CLOSEST RELATIVE)
Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
III. RENT
Current base rentals are:
    (Please check the appropriate boxes below)
I have sufficient income to cover current rent rate plus any additional services at Bethel Assisted Living Center for years.