Community Services Housing Application

BETHANY ST. JOSEPH CORPORATION

Community Services Housing Application

For Seniors Age 62+ Or Age 55 With Disability

Applicant 1: ______Applicant 2: ______

Date of Birth: ______Date of Birth: ______

Street Address: ______

City, State, Zip Code: ______

Telephone Number: ______

Preference (Circle one): Assisted Living | Independent Living

(Circle one): Studio (Eden House, Friendship House, Shelby Terrace, Windsor Place)

1-Bedroom | 2-Bedroom

I am interested in the following facility (Circle one):

Eden House | Friendship House | OnaMain | OnaTerrace | Welcome Home | Windsor Place

Laurel Manor | Mill St. Manor | Prairie Home | Salem Terrace | Shelby Terrace

Contact:

______Me about this application

______My family about this application

Family Contact: ______Phone Number: ______

Additional Information: ______

______

______

Signature of Applicant / Family Member Date

Applications are processed and filed in chronological order according to when they are received.

Mail completed applications to the facility of interest.

Assisted Living Senior Housing With Support Services

Laurel Manor – 108 17th Ave., S, Onalaska, WI 54650
Mill St. Manor – 840 Mill St., West Salem, WI 54669
Prairie Home – 620 Malin Ct., Holmen, WI 54636
Salem Terrace – 104 Lewis St., West Salem, WI 54669
Shelby Terrace – 2525 Shelby Road, La Crosse, 54601 / Eden House – 19475 Silver Creek Rd, Galesville, WI 54630
Friendship House – 323 Black River Rd, Westby, WI 54667
Mill St. Manor – 840 Mill St., West Salem, WI 54669
OnaMain – 920 Main, Onalaska, WI 54650
OnaTerrace – 1126 Main, Onalaska, WI 54650
Prairie Home – 620 Malin Ct., Holmen, WI 54636
Salem Terrace – 104 Lewis St., West Salem, WI 54669
Welcome Home – 3600 28th St., So, La Crosse, WI 54601
Windsor Place – 1020 Windsor St., La Crosse, WI 54603

All programs and services shall be made available without regard to Race, Creed, Gender, National Origin or Other Unlawful Grounds.

7/14