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Part B-Forms
Forms
Designated Assisted Living Level 4
- 2 -
Revised Feb. 17, 2015
Admission Process
Eligibility: An individual may start the application process with either The Evergreens Foundation or the Healthcare system. The lodge manager meets regularly with AHS representative to discuss
applications for Designated Assisted Living. Seton Healthcare Centre does all health assessments for placement in the DAL. Additionally,
Parks Canada has set its own criteria for residency within the Town of Jasper. Parks eligibility criteria are included along with this application and must be validated by the Lodge Manager
before admission is permitted. If Seton Healthcare Centre recommends placement and the individual meets Parks Canada criteria, The Evergreens Foundation will proceed with the application process.
Please contact Lorna Chisholm, Seton Healthcare Centre Manager, for more
information on DAL placements: 780-852-6600
Admission Documentation
1. A prospective resident must complete and submit the following forms from this package to
the Lodge Manager of the facility to which they are applying:
Application Form (pages 3-5)
Copy of most recent or Current Income Tax return Basis of Occupancy and Declaration (page 6)
Pre-Authorized Debit Form (page 7) Consent for Disclosure (page 8)
Responsible Relative/Guardian Form (page 9) ERS Agreement (page 10)
Applicable Jasper Residency Affidavit, please ask Manager for appropriate statutory declaration
Proof of Executor 2. Applications are processed in a timely fashion and prioritized.
3. Approval for admission rests with the CAO. Declined applications may be presented to the
Board of Directors for ratification or appeal. 4. A personal interview with the Lodge Manager or his/her designate must be arranged prior
to admission. This process allows the applicant to tour the Lodge facilities and to ask questions regarding operations.
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Revised Feb. 17, 2015
Application for Admission This confidential information is being collected in accordance with the Alberta Housing Act, in that it relates directly
to and is necessary to determine eligibility of applicants of the Evergreens Foundation Lodge Program. Personal
information contained herein may be disclosed if deemed necessary to assess eligibility of applicants. For further
information please contact the FOIP Coordinator for the Evergreens Foundation at 1-877-265-5444.
NAME:
Surname First Initial
ADDRESS:
Street/Post Office Box No. Town/City Postal Code
TELEPHONE: ALBERTA HEALTH CARE NUMBER:
BIRTH PLACE: BIRTHDATE:
(DD/MMM/YYYY)
MARITAL STATUS: Single Married
Widowed Divorced
LENGTH OF 1) In Canada _________ 2) In Alberta __________
RESIDENCE: 3) In Municipality ________ 4) other country ________
Are you a smoker? Yes / No
IN CASE OF EMERGENCY CONTACT:
NAME: RELATIONSHIP:
HOME PHONE: SECOND PHONE:
EMAIL ADDRESS (If Applicable):
COMPLETE ADDRESS:
STREET/PO Box No. CITY PROVINCE POSTAL CODE
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Revised Feb. 17, 2015
CONTACT PERSON FOR BUSINESS MATTERS
NAME: RELATIONSHIP:
HOME PHONE: SECOND PHONE:
EMAIL ADDRESS (If Applicable):
COMPLETE ADDRESS:
STREET/PO Box No. CITY PROVINCE POSTAL CODE
WILL: Does the Applicant have a Will? YES NO Proof of Executor needed (A copy of Will designating Executor or other legal document). Executor:
NAME ADDRESS PHONE
LIVING WILL (PERSONAL DIRECTIVE): **A COPY of the Living Will should be left on file with the Seton Healthcare Centre Manager.
**Living wills and/or wills are not required by The Evergreens Foundation; however, they may be
placed in a residents’ file for convenience.
PAYMENT OF ACCOMMODATIONS: Is the applicant able to meet the cost of rent from his/her own resources?
YES NO
If no, please state arrangements for payment of rent, medical and other expenses:
Rental payment in applicants’ present residence: ______________________
Utility costs paid in present residence: _______________________________
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Revised Feb. 17, 2015
INCOME: We require that you provide a copy of the most recent Notice of Assessment you received
from Revenue Canada. The Notice of Assessment is sent to every tax filer upon completion of the personal income tax form. Furthermore, this will be required each and every year of occupancy. The authority to collect this information is granted to The Evergreens Foundation
through Ministerial Order from the Province of Alberta and is done in compliance with the Freedom of Information and Privacy Act s. 34(2). It is used solely for determining eligibility
for grant funding and determining annual rental amount.
Please specify amount stated on Line 150 of your most recent Notice of Assessment
$________________
If married, do you and your spouse “Pension-income Split”? YES NO
Do you receive Alberta Seniors Benefit? YES NO
If applicable, does your spouse receive Alberta Seniors Benefit? YES NO
If married, have you and your spouse applied for “Involuntary Separation”? Yes NO
Do you receive the Supplementary Accommodations Benefit? YES □ NO □
Completion of an assessment by Seton Healthcare Centre and compliance with Parks Canada Residency Requirements are required before Admission will be approved.
___________________________ _________________________
Witness Signature of Applicant
_________________________ Date
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Revised Feb. 17, 2015
Questions you may wish to ask:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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Revised Feb. 17, 2015
Basis of Occupancy and Declaration
I, the Applicant, or the Legal Guardian of the Applicant, by signing this declaration, understand, acknowledge and agree to the following conditions related to my occupancy at
Alpine Summit Seniors Lodge (DAL), should my application be accepted. 1. That I have received a copy of The Evergreens Foundation’s Terms of Occupancy and
its attachments which, together with the Application for Occupancy, form the basis of my occupancy at Alpine Summit Seniors Lodge. I shall abide by the provisions, rules
and regulations thereof and any changes therein which are brought to my (or guardian’s) attention in written form, and I hereby explicitly waive any right I may
have at law to approve or consent to any such further changes; 2. That the relationship between The Evergreens Foundation and me is that of
licensor/licensee and my interest in the Lodge is that of a mere licensee, boarder or lodger;
3. That I agree all healthcare matters are primarily between me and Alberta Health
Services staff and that The Evergreens Foundation will only be informed of my health
condition/concerns as it pertains to my housing needs.
4. That I hereby forever discharge The Evergreens Foundation, its employees and agents, and Alberta Seniors from any and all actions or suits arising out of my occupancy at Alpine Summit Seniors Lodge of whatsoever nature and kind, excepting those caused
by gross negligence.
____________________________ _________________________
Witness Signature of Applicant or Guardian
_________________________ Date
- 8 -
Revised Feb. 17, 2015
Notice of Collection of Personal Information of Resident
Your personal information is being collected under the authority of the Alberta Social Housing Regulations. It will be used to determine your eligibility to become a resident and for
operating and administering the residence including:
• Posting your last name, initial and room number on the building directory
• Posting your last name and initial outside your room door • Alerting the kitchen to any special diet requirements and food allergies
• Posting your last name and initial on the laundry schedule, if applicable • Posting your name on a welcome sign • Posting any pictures taken of you during residence activities on the Activity Board
• Providing a contact name and phone number to the residence Manager to keep at home in case of an emergency after hours.
If you have any questions about this collection, please contact the CAO or the Administrative Assistant
at the main office, located at 102 Government Road, Hinton; or call (780) 865-5444 Monday through
Friday between 8:30 am and 4:30 pm.
Consent for Disclosure of Personal Information of Resident
I, _________________________________ hereby consent to the following disclosures of my
personal information:
Please cross out and initial any information that you do not want shared.
• Listing my name, photo, date of birth in the Residence Newsletter, on the Recreation
Calendar, on The Evergreens Foundation Web site, on The Evergreens Foundation’s
Facebook Page, and in the kitchen/coffee bar areas. ______ initial
• Listing any special diet requirements and food allergies on my place card in the dining room and on the Rolodex in the Manager’s office. _______ initial
• Placing my name and photograph(s) in the resident photo album. _______ initial
• Release of my DNR information (if posted on my door) to ERS personnel. _______ initial
I understand that my consent to the above disclosures is voluntary. My consent will remain in effect only for the period during which I am a resident. I understand that I may change or withdraw my consent at any time by giving written notice of the change or withdrawal to the
residence Manager.
Signed this _____________ day of ____________________, 20__.
____________________________________________
Signature of Tenant/Legal Guardian
This release is necessitated by the Freedom of Information and Protection of
Privacy Act legislation which was enacted on October 1, 1999.
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Revised Feb. 17, 2015
If you have any questions about this collection, please contact the FOIP Coordinator at the main office, located at 102
Government Road, Hinton or call (780) 865-5444 or toll free 1-877-265-5444 Monday through Friday between 8:30
am and 4:30 pm.
Your Legal Matters:
Does the Applicant have a Legal Guardian in place? YES NO
Does the Applicant have a Trustee? YES NO
**If the answer is YES to either of the above questions, the Lodge Manager will need
to discuss the nature of the relationship and have supporting documentation provided.
Does the Applicant have an Enduring Power of Attorney? YES NO
Does the Power of Attorney need to be “enacted”? YES NO
Does the applicant have a Personal Directive? YES NO
If YES, does the Personal Directive document authorize an individual(s) to make
healthcare decisions for you? YES NO
Upon move-in, please provide The Lodge Manager with a copy of your Power of
Attorney and Personal Directive.
NOTE: The Evergreens Foundation strongly recommends that a Power of Attorney
and Personal Directive be in place prior to move-in. If the manager has concerns
about the availability of family supports in the area, they may request that a Power of
Attorney and Personal Directive be in place before accepting the applicant into the
lodge.
Please see the next page for more information on Enduring Powers of Attorney &
Personal Directive.
Does the Applicant have an Executor named? YES NO
Executor:
NAME:
MAILING ADDRESS :
PHONE:
EMAIL ADDRESS (If Applicable):
- 10 -
Revised Feb. 17, 2015
Bulletin: Enduring Powers of Attorney & Personal Directive
An Enduring Power of Attorney is an important legal document you can use to appoint someone to
make financial and legal decisions on your behalf. If you are the one passing the authority to
someone else you are called the donor. The person you pass the authority to is called the
attorney. A Power of Attorney is "enduring" because its power continues after the donor becomes
mentally incapacitated or it can take effect after the donor becomes mentally incapacitated.
Choosing an attorney
The attorney should be someone you trust and are confident will act in your best interest. Your
attorney should also have the knowledge and experience to be able to deal with your property and
finances. It is also important to ask the attorney beforehand to ensure that they are willing to
accept the appointment. If you are considering appointing a financial institution, you will want to
ensure that you are aware of any fees that may be charged.
Any adult or financial institution can be appointed to act as attorney;
The attorney appointed does not have to live in Alberta;
You can appoint both a person and financial institution to act;
The Public Trustee cannot act as an attorney.
You may want to hire a lawyer to help
While you don't have to hire a lawyer to have an Enduring Power of Attorney made, it is
recommended. A lawyer can guide you through the process. They can explain safeguards and help
you better understand possible limitations and powers. They can also help you make sure the
Enduring Power of Attorney is drafted so it only takes effect when the donor becomes sufficiently
disabled, and they can review the document periodically with you. Often, a lawyer will prepare an
Enduring Power of Attorney in combination with a Will and a Personal Directive.
To give someone the authority to look after your personal and non-financial matters you
will need a different document called a Personal Directive.
You can make a Personal Directive which appoints an Agent to make personal and non-financial
decisions on your behalf if you become mentally incapacitated and unable to make these types of
decisions yourself. If you become mentally incapacitated and do not have a Personal Directive,
then someone may need to go to Court to obtain an order appointing a co-decision-maker or a
guardian who will make decisions in your best interests.
**The preceding information is taken from the Alberta Human Services Website. Go to
http://humanservices.alberta.ca and Search “power of attorney” for more information.
- 11 -
Revised Feb. 17, 2015
THE EVERGREENS FOUNDATION
Responsible Relative/Guardian Form
I, _________________________, BEING THE RESPONSIBLE RELATIVE/GUARDIAN Name of Responsible Relative/Guardian
OF THE APPLICANT, ______________________, DO HEREBY AGREE THAT SHOULD Name of Applicant
THE APPLICANT REQUIRE ANY SPECIAL CARE PRODUCTS OR PERSONAL SUPPLIES NOT COVERED BY ALBERTA HEALTH, I WILL PROVIDE SUCH IN A TIMELY MANNER TO THE
APPLICANT UPON HIS/HER ACCEPTANCE TO THE DESIGNATED ASSISTED LIVING FACILITY (DAL) AND THROUGHOUT HIS/HER RESIDENCY THEREIN.
IF I HAVE NOT SUPPLIED ALL NECESSARY PRODUCTS, AHS MAY AT THEIR DISCRETION PURCHASE SUCH ITEMS AND BILL DIRECTLY TO THE RESIDENT/GUARDIAN.
FURTHER, AS THE RESPONSIBLE RELATIVE/GUARDIAN, I WILL ENSURE THAT RENTAL PAYMENTS WILL BE MADE ON OR BEFORE THE FIRST OF EACH MONTH.
RENT WILL BE PAID BY:
□Post-dated cheques □Automatic Withdrawal □Other:_______________
Dated this day of 20___.
WITNESS: RESPONSIBLE RELATIVE/GUARDIAN:
__________________________ ____________________________
- 12 -
Revised Feb. 17, 2015
EMERGENCY RESPONSE SYSTEM
Sunshine Place Parkland Lodge Pine Valley
Whispering Pines Alpine Summit Name of Resident:
I am in receipt of an Emergency Response System pendant belonging
to the Evergreens Foundation. I accept full responsibility for this pendant and agree to the following:
a) I will leave this pendant at the Lodge if I plan to be away overnight or hospitalized
b) When I leave the Lodge, I will return the pendant to the office in
good working condition.
c) I will reimburse the Evergreens Foundation in the amount of
$140.00 (one hundred and forty dollars) if the pendant is lost, stolen or damaged.
I realize that this system is for emergency use only and abuse of the pendant
will result in my forfeiting my right to use the system. DATE: _______________________
NAME: _______________________ Signature
WITNESS: _______________________ Signature
I have been made fully aware of the Emergency Response System and its advantages. I decline the use of an ERS pendant while a
resident of Lodge. I realize that I may request access to this program at a future date if I feel it is necessary.
DATE: _______________________
NAME: _______________________
WITNESS: _______________________