APPLY NOW

Please fill out this form as best as you can for consideration of residency in our facility/program where respect, dignity and comfort comes first.

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Current Address

Gender

Emergency Contacts (Name, Relationship, Phone number)

Are you comfortable with a shared living space?

What is your payment method?

SSI

SSDI

Disability

Private Pay

Known Medical and/or Chronic Conditions (e.g, diabetes, heart issues, Asthma)

Any Current Medications? (Place N/A if none)

Desired Move-In Date

Mobility

Fully Independent

Cane/Walker

Wheelchair

Other

Have you been convicted of violent crimes?

Yes

No

Do you agree to live in a drug and alcohol-free environment?

Yes

No

Do you agree to follow community rules and guidelines?

Yes

No

How did you hear about our program/services?

Additional Notes

I, the undersigned, certify that the information provided above is accurate to the best of my knowledge. I consent to the staff of Mj's Safety Nest independent Living Facility using this information to provide appropriate services.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Thank you for taking the time to apply. We will be in contact with you within 72 hours.