Fernwood Place Application

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Name: *

Bedroom(s) required: *

Room Preference (if applicable):

Mailing Address: *

Telephone #: *

Date of Birth (Applicant 1): *

Month

Day

Year

Date of Birth (Applicant 2):

Month

Day

Year

Next of Kin Name: *

Next of Kin Telephone #: *

Comments:

Pre-Admission Medical Information

Is the applicant(s) currently a client with homecare or mental health: *

Yes

If yes, name of Case Coordinator or Mental Health Proctor:

If yes, List the services currently provided by homecare/mental health:

Comments:

I declare the above information is correct and accurate to the best of my knowledge. I understand that this application does not constitute an obligation to provide me with accommodation.

I acknowledge that my signature indicates that I am aware that this apartment complex is smoke-free and a breach of this may result in termination of tenancy.

Signature: *

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