Part B-Forms

Forms

Designated Assisted Living Level 4

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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

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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):

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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.

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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:

__________________________ ____________________________

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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: _______________________