Apply for Residency

If you’re at least 55 years of age, you’re eligible to apply for residency at Frederick Living, though in cases of special need, admission may be made at a younger age. If you’re interested in joining our community, please give us a call at (610) 754-7878 or complete the online application below!

The information asked for on this form is needed to evaluate the applicant's request for admission. All information will be considered by the Admissions Committee and will be held in strict confidence. The acceptance of this form does not bind either party to admission. Failure to complete the application in its entirety could result in denial of consideration for admission. If you are making the application on behalf of another person, please answer each question with regard to the applicant. All required fields are marked with a *, but please fill out the application as completely as possible. If you would prefer, you can also download and complete a PDF of our application.



Personal Information

Male      Female

Place of Birth

Single      Married      Widowed      Divorced

Spouse Information

Place of Birth

Financial Information

Financial Status (Specify all income and assets involving the applicant)

Regular Monthly Income Amounts

Amount Address where received
Social Security $
Veteran's Pension $
Railroad Retirement $
Other Retirement Annuity $
Other Pension $
Rental Income $
Business Income $
Other $
Cash Assets/Investments

Amount Bank Owners
Checking Account $
Savings Account $
Stocks/Bonds

Name of Company Current Value Owners
$
$
$
Certificate of Deposit

Date Due Amount Owners
$
$
$
Real Estate

Type
(residential, rental etc.)
Estimated Value Owners
$
$
$
Life Insurance

Company Name Face Value Cash Value Owners
$ $
$ $
$ $
Other Miscellaneous Income
Other Assets
     Yes      No
     revocable     or     irrevocable ?
Is any income paid to another person for the applicant (i.e. Representative Payee)?
* Yes      No
Have there been any assets transferred to another person in the last five years?
* Yes      No
If yes, please specify amount: $
and to whom it was transferred:

Information, Agreements & Signatures

Who is Eligible?

Men and women who are 55 years of age or over at the time the application is filed. In cases of special need, admission may be made at a lower age.

Application Review Process

Upon receipt of this application, the application will be reviewed by committee, and you will be contacted to discuss eligibility and to discuss next steps.

Frederick's Mission

In the spirit of Christian love, Frederick Living cares for and enriches the lives of older adults, while valuing the staff, volunteers and community that serve them.

Values

Respect, Integrity, Compassion, Excellence

Frederick's Non-Discrimination Policy

It is the policy of FMC to voluntarily comply with the provisions of the Federal Civil Rights Act of 1964, The Fair Housing Act and the Pennsylvania Human Relations Act (43 P.O. 5941, et seq.), and all requirements imposed pursuant thereto to the end that no person shall on the grounds of race, color, national origin, ancestry, age, sex, religious creed, non-job related handicap or disability or use of guide or support animal because of blindness, deafness or physical handicap be excluded from participation in, be denied benefits of or otherwise be subject to discrimination of any care or service, except with respect to age, to the extent permitted as housing for senior adults.

All information has been provided to the best of my knowledge. I understand that any misrepresentation or willful omission of information on this application will disqualify the prospective resident from admission and may be cause for discharge if discovered after resident’s admission.


Typing your name below constitutes the signing of this form and results in the same binding agreements as a physical signature.

    

Person completing form, if other than applicant