Application for Tenancy
SSL certificates
Applicant 1
First Name:
*
Last Name:
*
Birthday:
Month:
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Year:
1919
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Applicant 2
First Name:
*
Last Name:
*
Birthday:
Month:
1
2
3
4
5
6
7
8
9
10
11
12
*
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*
Year:
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
*
Application Date:
8/31/2024
Desired Move in Date:
*
Address Line 1:
*
Address Line 2:
City:
*
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
*
Phone Number:
*
Cell
Home
Work
Other Phone Number:
Cell
Home
Work
E-mail Address:
*
Referred By:
A Smoke Free Campus
No Pets
1st Preference:
Studio
One Bedroom
Two Bedroom
2nd Preference:
Studio
One Bedroom
Two Bedroom
Additional Information:
Have you, or any person named above, been convicted of a crime?
No
Yes
Other
Explanation:
*
Have you, or any person named above, been evicted or asked to leave?
No
Yes
Other
Explanation:
*
Are you a family member of Facmily Care (Western Wisconsin Cares)?
Yes
No
Checking Account Amount:
$
*
*
Saving Account Amount:
$
*
*
Other: (Real estate, stocks, bonds, pension, SSI, etc…)
Social Security Number:
(xxx-xx-xxxx format)
*
*
Medicare Number (including letter):
Medical Assistance Number:
*
Prescription Insurance Information:
If renting, current landlord information is required:
Name of apt bldg if applicable and landlord:
Address & Phone:
A tenant must inform us of when their funds reach an estimated value of 6 months worth of the cost to live at Hillview Terrace. At that time the tenant will be advised to contact the ADRC and either must apply for assistance, a family care program or subsidize their rent and services through other sources such as family members. We currently have a contract for our studios with the family care program.
All applications are processed, filed chronologically Mon-Fri. according to when they’re received. We’ll contact you soon thereafter. All applications are nonbinding & do not guarantee admission. Prior to admission a functional assessment will be done by the manager & RN. The purpose of the assessment is to assure that we are able to meet your needs and care for you safely.
Please review criteria for admission prior to submission.
SSL certificates
Hillview Assisted Living - Admission Critieria
• Be 62 years of age or older;
• Be able to accept risk, sign an agreement; Is competent & does not have a guardian or activated POA;
• Be able to make care decisions or share apt with competent spouse or other with legal responsibility;
• Be capable of recognizing danger, summoning assistance and expressing need;
• Be generally alert and oriented to time, place and persons;
• Be capable of acceptable interaction with others without aggressive or combative behaviors;
• Require fewer than 28 hours of services per week from Hillview Terrace
• Not have a medical condition that requires immediate availability of a nurse (24) hours a day;
• Be able to move about safely with or without assistive devices such as canes, walkers, etc.
• Be able to assist in transfer (no two-person transfers or use of a mechanical lift for transfer);
• Be able to follow the facilities house rules, policies and procedures
• Be able to eat without supervision or assistance;
• Be continent of bowel and bladder or else be on a successful SELF-managed incontinence program.
• Allow the facility to conduct a comprehensive pre-admission assessment, financial and background check; admission may be denied based on the outcome of these checks
• Tenant/family required to maintain responsibility of making medical appointments & for escorting & transportation of tenants to medical appointments; unless part of service agreement
• Provide to the facility: Evidence from a physician that potential resident is free from communicable disease; TB test; and evidence of financial viability for at least 2 years
According to the best of my knowledge, I meet the criteria above and the foregoing information is complete & accurate. Falsifying or an incomplete application is reason for denial. If application is approved, we will visit with you for our functional screen to ensure we can safely care for you. A lease is then signed. There is no rental agreement with the facility before the signing of the lease. I hereby authorize the Manager to investigate my credit/financial responsibility, income & rental background history. My performance under any lease or rental agreement that I may enter into with the manager may be reported to a reporting agency. It is the Managers discretion for discharge from Hillview Terrace.