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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: 8/4/2015   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?
Explanation:
Have you, or any person named above, been evicted or asked to leave?
Explanation:
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.
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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.