Riverside

Alaska's Premier Assisted Living

Resident Application Form
  1. Primary Contact Name(*)
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  2. (Individual completing form)
  3. Address(*)
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  4. City(*)
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  5. State(*)
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  6. ZIP(*)
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  7. Home Telephone
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  8. Mobile(*)
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  9. Email(*)
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  10. Potential Resident Name(*)
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  11. Age (Approximate if not certain)(*)
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  12. Gender(*)
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  13. Marital Status(*)
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  14. Living Situation(*)
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  15. Potential Resident's Funding Source(*)
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  16. Is Potential Resident currently receiving Medicaid services (such as PCA)?(*)
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  17. Mobility devices used(*)
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  18. Potential Resident Care Needs (please check mark those categories where assistance is needed)
  19. A. Medications(*)
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  20. B. Dressing(*)
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  21. C. Bathing(*)
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  22. D. Toileting/Hygiene(*)
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  23. E. Mobility/Transferring(*)
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  24. F. Memory Care(*)
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  25. Describe any physical/health concerns or additional care needs you would like to share with us:
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  26. Check YES if you would like to secure a reservation with Riverside Assisted Living today:
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Weather

45°
°F | °C
Showers
Humidity: 95%
Thu
Scattered Showers
45 | 48
7 | 8
Fri
Scattered Showers
46 | 52
7 | 11