Download the Application Step 1 of 4 25% I am ready for admission as soon as an opening occurs? Yes No Please select the location(s) you prefer. Adrian Chillicothe Independence Ashland Arcadia Valley (Ironton) Ozark Smithville (Fall 2023) Tri-County (Vandalia) If more than one location is preferred, please list your order of preference:Please share briefly why you prefer this campus:(Required)Living Situation for Residency Independent Living - Resident must be able to fully care for themselves. Light housekeeping and all yard work and apartment repairs provided. Assisted Living - Licensed care for those needing minimal assistance. Meals and housekeeping provided. (Not yet available in Adrian, Ashland, Tri-County) Nursing Care - Nursing staffed 24 hours/7 days and access to medical services available through area physicians. (Not available in Ashland or Chillicothe) Name First Last Potential Resident InformationName (First Applicant) First Middle Last Spouse Name (Second Applicant) First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone NumberCell NumberEmail(Required) Veteran Yes No Veteran's Spouse/Widow? Yes No Marital Status Never Married Married Widowed Divorced Church Membership Church Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone number for your current churchPhysician's Name First Last Physician's PhoneLegal Information Do you have health insurance? Yes No What kind of health insurance? Medicare Medicaid (MO Healthnet) Supplement Long-term care insurance? Yes No Pre-paid funeral arrangement? Yes No Do you have a Durable Power of Attorney (POA) or Legal Guardian? Yes No Name of POA or Guardian Name First Last Phone number of POA or GuardianDo you have an Estate Plan? Yes No Do you have an Advanced Health Care Directive? Yes No Have you disposed of any assets other than customary living expenses? Yes No Reason for disposal?Do you anticipate needing financial assistance within the next 5 years? Yes No *You will need to complete a financial application. Upon completion of this form, you will be directed to download the application. If you have an email address, you will also be e-mailed the form with instructions on how to turn it in.Please add me to the list for news and information about Baptist Homes & Healthcare Ministries Yes No *You will need to complete a financial application. Upon completion of this form, you will be directed to download the application. If you have an email address, you will also be e-mailed the form with instructions on how to turn it in.I Agree(Required) Yes No NameThis field is for validation purposes and should be left unchanged. Δ
