Apply for

Seniors Housing

Please keep in mind that placement is determined by need rather than the date of application.

Seniors Housing Application

The following information will be used to assess your eligibility for lodge accommodation; it will also be used to establish your priority rating score, which is used to measure our applicants’ levels of need.

Your personal information is confidential and will be maintained in storage with restricted access. This information is being collected and protected in accordance with the Privacy Provisions of the Freedom of Information and Protection of Privacy Act.

This personal information is being collected under the authority of the Alberta Housing Act and by the policy of the Newell Foundation Board of Directors. It will be used for the following reason: determine suitability for residency, determine needs rating and for communication with health care and social agencies that may provide you with care of any type. The privacy provisions of the Freedom of Information and Protection of Privacy Act protect it.

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Personal Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Phone(Required)

Current Address(Required)

Street Address City Province Postal Code

Social Insurance Number

Alberta Health Care Number(Required)

Gender:(Required)

Male

Female

Other

Marital Status:(Required)

Single

Married

Seperated

Divorced

Widowed

Other

Please select which applies:(Required)

Canadian Citizen

Landed Immigrant

Other

Length of residency in Alberta:(Required)

In which municipality do you currently reside:(Required)

Do you drive?(Required)

Yes

Name of your Physician:(Required)

First Last

Physician's Phone Number:(Required)

Emergency Contacts:(Required)

Please list the People you want us to contact, in order of priority, in case of an emergency and concerning health and social needs. All correspondence will also be sent to the first contact. Please also list, if applicable, the following: Spouse, Executor of your Will, Social Worker, Trustee, Guardian, Agent name in Personal Directive or Power Attorney. Indicate this under Relationship.

Name

Relationship to you

Phone Number

Address

Will you have a Co-Applicant for the subsidized unit?

Yes

Has your Co-Applicant already applied for a subsidized unit through the Newell Foundation?

Yes

Co-Applicant Information

After completing this entire form and including your Co-Applicant's personal details below, please have your Co-Applicant complete their own copy of this application form. This allows us to gather all necessary information for both parties.

Co-Applicant's Name(Required)

First Last

Co-Applicant's Phone(Required)

Co-Applicant's Date of Birth(Required)

MM slash DD slash YYYY

Co-Applicant's Current Address(Required)

Street Address Address Line 2 City Province Postal Code

Co-Applicant's Social Insurance Number(Required)

Co-Applicant's Alberta Health Care Number(Required)

Co-Applicant's Marital Status:(Required)

Single

Married

Seperated

Divorced

Widowed

Other

Please select which applies to the Co-Applicant:(Required)

Canadian Citizen

Landed Immigrant

Other

Co-Applicant's Length of residency in Alberta:(Required)

In which municipality does the Co-Applicant currently reside:(Required)

Does the Co-Applicant drive?(Required)

Yes

Name of Co-Applicant's Physician:(Required)

First Last

Co-Applicant's Physician's Phone Number:(Required)

Co-Applicant's Emergency Contacts:(Required)

Please provide at least one.

Name

Relationship to you

Phone Number

Address

Nutrition

Please note that Newbrook Lodge does not offer a special diet. (i.e., diabetic, celiac, etc.)

Are you physically able to cook for yourself?(Required)

Yes

Does your current accommodation have appropriate cooking facilities?(Required)

Yes

Do you receive regular meal assistance through others?(Required)

Yes

Do you currently use a “Meals on Wheels” program?(Required)

Yes

Are you interested in eating well/have a good appetite?(Required)

Yes

Are your nutritional needs met through your eating habits?(Required)

Yes

Do you require assistance or supervision when eating?(Required)

Yes

Do you have any special dietary requirements?(Required)

Yes

Special dietary requirements:(Required)

Please note that at this time we are unable to provide modified diets.

Life Enrichment

Are activities that enhance the following areas currently available to you? If transportation to these activities available to you, please also select 'Transportation' in addition to your answer.

Physical Health(Required)

Yes

Transportation

Emotional Well Being(Required)

Yes

Transportation

Spiritual(Required)

Yes

Transportation

Social(Required)

Yes

Transportation

Intellectual(Required)

Yes

Transportation

Cultural(Required)

Yes

Transportation

Please tell us about what you enjoy:(Required)

Such as your interests, hobbies, career, training, education, expertise, etc.

Access to Service/Amenities

Are you able to access groceries on your own?(Required)

Yes

Are you able to access health-related products on your own?(Required)

Yes

Are you able to attend appointments on your own?(Required)

Yes

Are you able to drive, do you have acquaintances that will transport you?(Required)

Yes

Are you able to access public or specialized transportation?(Required)

Yes

Current Environment

Name of the facility you are currently living in, if applicable:

Are you subjected to abuse in your current accommodation?(Required)

Yes

Do you require a more controlled or supportive environment due to risk from: Mental health concerns acceptable under lodge criteria?(Required)

Such as mild forgetfulness or anxiety.

Yes

If you require a more controlled or supportive environment, please explain:(Required)

Physical health concerns acceptable under lodge criteria?(Required)

Such as increased fall hazard or oxygen therapy.

Yes

If you have physical health concerns, please explain:(Required)

Are there any other external factors that are putting you at risk?(Required)

Yes

If you have external factors that put you at risk, please explain:(Required)

Do you currently receive or require Home Care Services?(Required)

Yes

If you currently receive or require Home Care Services, please explain:(Required)

Current Environment Maintenance

Are you able to perform the following basic maintenance tasks without assistance?

Snow and ice removal(Required)

Yes

Yard work(Required)

Yes

Proper housekeeping(Required)

Yes

Basic home maintenance(Required)

Yes

Current Environment Structural

How does your current housing rate given your needs?

Is it suitable?(Required)

Yes

Is it unsuitable but affordably adaptable?(Required)

Yes

Is it unsuitable and not affordably adaptable?(Required)

Yes

Current Environment Non-Structural

How does your current housing rate given your needs?

Is it inadequate due to problems with other residents?(Required)

Yes

Is it inadequate due to overcrowding?(Required)

Yes

Are you about to lose your current accommodation?(Required)

Yes

Physical Well Being

Are you able to dress yourself without assistance?(Required)

Yes

Are you able to get to meals/activities without assistance?(Required)

Yes

Are you able to get to meals/activities without being reminded?(Required)

Yes

Are you able and willing to regularly groom yourself?(Required)

Yes

Are you able to manage your own toileting?(Required)

Yes

Do you require assistance with bathing?(Required)

Yes

Do you smoke?(Required)

Yes

Do you have allergies?(Required)

Yes

Please explain your allergies:(Required)

Do you have diabetes?(Required)

Please note we do not offer a special diet.

Yes

Do you suffer seizures?(Required)

Yes

Do you use a catheter?(Required)

Yes

Do you have a colostomy?(Required)

Yes

Do you use supplemental oxygen?(Required)

Yes

Do you have a pacemaker?(Required)

Yes

Is your vision adequate for getting around?(Required)

Yes

Is your vision adequate for reading?(Required)

Yes

Is your hearing adequate for socializing?(Required)

With hearing aids if necessary.

Yes

Do you currently receive or require assistance with your medications?(Required)

Yes

Do you have any barriers to communication?(Required)

Yes

If you have any barriers to communication, please explain:(Required)

Mental Well Being

Are you able to manage your personal finances without assistance?(Required)

Yes

Are you able to schedule your appointments without assistance?(Required)

Yes

Are you able to determine whether your needs are being met?(Required)

Yes

Are you able to make your own decisions?(Required)

Yes

Mobility

Do you have trouble with stairs in your current accommodation?(Required)

Yes

Do you have trouble accessing areas of your current accommodation?(Required)

Yes

Do you have trouble gaining access to your accommodation from outside?(Required)

Yes

Do you require assistance moving around your current accommodation?(Required)

Yes

Do you use a:(Required)

Cane

Walker

Wheel Chair

Current Family/Community Support Situation

Do you have family/friends nearby who assist with transportation?(Required)

Yes

Are you experiencing an appropriate level of social interaction?(Required)

Yes

Accessing other suitable and affordable housing options in your community is:(Required)

Absolutely Impossible

Practically Impossible

Very Difficult

Income

All incomes must be verified upon acceptance as a tenant.

Do you receive the Alberta Seniors Benefit or would you qualify for the Lodge Assistant Grant?(Required)

Yes

Please attach a copy of your most recent Income Tax Return (Notice of Assessment).

A copy of your most recent Income Tax return Notice of Assessment must be attached to the application in order to determining the amount of rent to be charged. Otherwise, rent charges may not be accurate according to income.

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 2 MB.

Location

Which is your preferred location of Seniors Self-Contained Housing?(Required)

Newbrook Lodge - Brooks, Alberta

Playfair Lodge - Bassano, Alberta

Please explain, in detail your reasons for wanting to reside in the Newbrook or Playfair Lodge:(Required)

Eg. I wish to relocate to be near my...

Consent

Did someone other than the applicant enter the Information on this form?(Required)

Yes

Please explain why the applicant was not able to enter the information on their own:(Required)

Consent

The information provided above is accurate to the best of my knowledge.

I understand that this is just an application and that it is not an agreement on the part of NEWELL HOUSING FOUNDATION, or its agents to provide me with rental accommodation.

I further acknowledge the right of NEWELL HOUSING FOUNDATION, or its agents at any time prior to the execution and delivery to me of a lease, to withdraw or cancel, without penalty or liability for damages or otherwise, any prior approval of this application.

I authorize NEWELL HOUSING FOUNDATION, or its agents to investigate any or all of the statements made by me in this application, being fully aware that any discovery of false statement shall cancel any further consideration of my application.

I further agree that I am obligated to advise NEWELL HOUSING FOUNDATION, or its agents, in writing, of any changes in family composition, gross family income, assets, or change of address should they occur.

I hereby consent to the Newell Foundation obtaining information concerning my health and social needs from any healthcare professionals agencies, that in the opinion of the Newell Foundation, is needed for determining my acceptability for residency. This may include for example but is not limited to the following: Home Care Staff, Physicians, Mental Health Workers, Social Workers, Therapeutic Staff, and Nurses.

Refusal to consent to the Newell Foundation obtaining health and social information may result in refusal of accommodation.

I agree.

All approved applicants will be placed in a suitable housing program based on the highest need first and then in the order in which the application was received. Please note that the Newell Housing Foundation will determine which housing program will best suit your household needs after the initial assessment and approval of your application.

The following information will be used to assess your eligibility for lodge accommodation; it will also be used to establish your priority rating score, which is used to measure our applicants’ levels of need.

This information is being collected and protected in accordance with the Privacy Provisions of the Freedom of Information and Protection of Privacy Act.

This personal information is being collected under the authority of the Alberta Housing Act and by the policy of the Newell Foundation Board of Directors. It will be used for the following reason: determine suitability for residency, determine needs rating and for communication with health care and social agencies that may provide you with care of any type. The privacy provisions of the Freedom of Information and Protection of Privacy Act protect it.

Please be aware that once you have submitted your application online, and included all required supporting documentation, it must be signed in the presence of a Commissioner for Oaths in order to be processed.

Please be aware that once you have submitted your application online, it must be signed in the presence of a Commissioner for Oaths in order to be processed.

Please visit our Central Office at 500 3rd Street East, Brooks, Alberta, T1R 1P6 to sign your application in order for it to be processed.

Do you Have a Co-Applicant?

Comments

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