Application for Tenancy

SSL certificates
Applicant 1    
First Name:
Last Name:
Birthday: Month:   Day:   Year:
Applicant 2  
First Name:
Last Name:
Birthday: Month:   Day:   Year:

Application Date: 4/13/2024   Desired Move in Date:
Address Line 1: Address Line 2:
City: State: Zip:
Phone Number:      
Other Phone Number:      
E-mail Address:
Referred By:

A Smoke Free Campus
No Pets
1st Preference:  
2nd Preference:  

Additional Information:
Have you, or any person named above, been convicted of a crime?
Have you, or any person named above, been evicted or asked to leave?
Are you a family member of Facmily Care (Western Wisconsin Cares)?

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.