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Admission Application Agreement

If my application is accepted, admission to and continued residency at Countryside Christian Community shall be made subject to the following conditions:

A.I shall abide by operating policies of Countryside Christian Community in effect at all times.

B.In event of my failure to conform to any of the policies, I shall, upon written notice from the Home, peaceably remove myself and my belongings from Countryside Christian Community within 30 (thirty) days of such notice.

C.In the event that it is not feasible for Countryside Christian Community to continue to care for me because of a change in my  mental or physical health or because of the endangerment of the health or safety of the residents or staff of Countryside Christian Community, Countryside Christian Community may transfer me to another facility provided that, except in the case of an emergency that arises from events beyond the control of Countryside Christian Community or from my physical or mental condition, Countryside Christian Community provides reasonable notification to me prior to the transfer in order to allow reasonable time for preparation for the transfer.

D.Countryside Christian Community may terminate, at any time, any contract or agreement between it and me because any statement, answer, representation, description, or omission made by me on this application is false, inaccurate, or misleading.

E.I hereby agree to pay all charges in accordance with the rates and terms set forth by the Board of Directors of Countryside Christian Community.  Room, board and other fixed charges are payable upon receipt of a statement.  If I become unable to do so, I hereby instruct my Power of Attorney to do so in my behalf.  Should my account become delinquent, Countryside Christian Community is hereby authorized to proceed to arrange for payment of the account at my expense.

F.In the event that I become unable to pay Countryside Christian Community for the services that are being provided to me, I will co-operate in completing and executing any application for Medicaid or any other state or federal funds that might be available to pay for the charges for such services.

G.I hereby agree to provide written contact to Countryside Christian Community as soon as my needs or intentions change requiring services or care other than those I have indicated in this application.

H.This agreement shall be binding on me, my estate and my heirs and assigns.

Applicant’s or Responsible Party’s signature: __________________________________ Date: ____________

(Consideration of this application for admission or a waiting list will not be made without applicant’s signature!)

Witness:Countryside Christian Community Representative:

_________________________________________________________________________

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