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 Ashland Arcadia Valley (Ironton) Ozark Shelbina Smithville Tri-County (Vandalia) If more than one location is preferred, please indicate first and second choice:This field is hidden when viewing the formPlease share briefly why you prefer this campus:Living Situation for Residency Independent Living - Available living arrangements vary by campus. Resident(s) must be able to fully care for themselves. Light housekeeping, all yard work, and apartment repairs provided. (Arcadia Valley, Ozark, and Ashland only) Residential Care - Independent Living with protective oversight by a trained individual. Resident may need little assistance with daily activities and is required to be able to make a path to safety unassisted. (Tri-County only) Assisted Living - Licensed care for those needing minimal assistance. Meals and housekeeping provided. (Arcadia Valley and Ozark only. Adrian and Ashland coming soon!) Memory Care - Offers a secure setting for those with cognitive decline which includes a spacious and comfortable outdoor environment, special activities for the residents, and staff specifically trained in the care of residents with a variety of dementia diagnoses. (Shelbina and Tri-County only) Skilled Nursing - Nursing staffed 24 hours/7 days and access to medical services available through area physicians. (Adrian, Arcadia Valley, Shelbina, and Tri-County only. Ashland and Smithville coming soon!) This field is hidden when viewing the formIf Independent Living, then Preferred Unit Style: Name of Person Completing the Application First Last Potential Resident InformationName (First Applicant) First Middle Last Spouse Name (Second Applicant) First Middle Last Marriage Date Month Day Year 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 Home NumberCell NumberEmail(Required) Veteran Yes No Veteran's Spouse/Widow? Yes No Military BranchMarital Status Never Married Married Widowed Divorced Separated Church Membership Church NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone number for your current churchThis field is hidden when viewing the formPhysician's Name First Last This field is hidden when viewing the formPhysician's Phone Legal InformationDo 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 If Yes, is it paid in full? Yes No If No, what is the amount owed?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 Monthly Income: Social Security (list amount)Monthly Income: Retirement (list amount)Monthly Income: VA Benefits (list amount)Monthly Income: Other (list amount)List all debts and amounts owedAssetsHave you disposed of any assets other than customary living expenses? Yes No Reason for disposal?Are any of the following assets owned jointly with another person? Yes No Checking Account(s) Joint Owner Total ValueSavings Account(s) Joint Owner Total ValueMoney Market Account(s) Joint Owner Total ValueU.S. Savings Bonds Joint Owner Total ValueCertificate(s) of Deposit Joint Owner Total ValueIRA(s) Joint Owner Total ValueAnnuities Joint Owner Total ValueStocks/Bonds/Mutual Funds Joint Owner Total ValueLife Insurance Joint Owner Total ValueReal Estate Joint Owner Total ValueVehicle(s) Joint Owner Total ValueHousehold Items Joint Owner Total ValueAntique Collections Joint Owner Total ValueIndebtedness Due You Joint Owner Total ValueFor assets with joint owners, please list the type of asset along with the name of the joint owner.Please add my name to the mailing list for news and information about Baptist Homes. Yes No If yes, please check below whether you prefer e-mail or postal mail communications. Email Postal Mail Both I HEREBY AFFIRM:(Required)that I am submitting this Application for Residency to Baptist Homes of my own free will and the information herein is true and correct to the best of my knowledge. I understand that my name will be added to the application database and all admissions are based on availability and type of residency. I understand the completion and submission of the Application for Residency does not imply or guarantee residency at Baptist Homes. Baptist Homes reserves the right to refuse admission to any person whose needs cannot be met by the facility. Yes No EmailThis field is for validation purposes and should be left unchanged. Δ
