DAYCARE admissionAPPLICATION
Name: / Docket No:
Date of Birth: / CINICO No:
Admission Date: / Discharge Date:
Attendance SCHEDULE
M T W T F / Pick Up Time:
Hours: / Drop Off Time:

Next of Kin Details

Contact (1): / Telephone:
Relationship to patient / Mobile:
Contact (2): / Telephone:
Relationship to patient / Mobile:
Contact (3): / Telephone:
Relationship to patient / Mobile:

Personal Information

Religion: / Church:
Doctor: / Telephone:

Payment Information

Social Services Contact: / Telephone
Amount Per Month:
Private Fund Contact: / Telephone
Amount Per Month/Week/Day:

interests

Resident Outings / Assisting with serving Meals
Gardening / Arts & Crafts
Playing Piano (Entertainment) / Reading
Exercise Program / Other
Guarantee and indemnity in favour
Of
The Pines Retirement Home (“The Pines”)

In consideration of The pines offering at my request residential facilities to ______(the “Resident”) I, the undersigned, by way of indemnity and not as mere surety hereby irrevocably undertake to pay and satisfy to The Pines on demand each and every sum of money which is now or shall at any time hereafter be owing by the resident to The Pines.

i)If and whenever the resident shall make default in the payment of any amount when due to The Pines, the undersigned will within seven (7) days of receipt by the undersigned of The pines written demand pay such amount as is owed by the Resident to The Pines.

ii)The liability of the undersigned under this Guarantee and Indemnity shall be irrevocable and unconditional and shall not be impaired or discharged by any reason of:

iii)Any time or indulgence granted to the Resident by or with the consent of The Pines;

iv)The pines releasing or abstaining from enforcing any other security, which The Pines may have taken as a security for sums, owed to it by The Pines.

v)Any variation in the terms on which residential accommodation is provided to the Resident by The Pines including, but not limited to, any increase in the fees payable by the resident to The Pines;

vi)Any other circumstance, contingency or a consideration whatsoever which might constitute a legal or equitable discharge for surety or a guarantor.

The undersigned confirms that he/she has not taken from the Resident either directly or indirectly any security in respect of the obligations of the undersigned under this Guaranteed and Indemnity and agrees that he/she will not prove in the bankruptcy of the resident in competition with The Pines in respect of any payment due from the Resident until all monies owing to The Pines by the Resident have been paid in full.

The undersigned herby agrees that so long as he/she shall be under any actual or contingent liability hereunder he/she shall not be entitled to share in and/or succeed to or benefit from (by subrogation or otherwise) any rights The Pines may now or hereafter have as security for the obligations (whether contingent or otherwise) of the resident to The Pines or any related security.

The undersigned agrees that it shall not be released from this Guarantee until The Pines shall cease to provide or reserve residential accommodation for the resident and all mounts owing by the Resident to The Pines have been paid in full

All notices to be served by The Pines on the undersigned may be served on the guarantor by posting the same by regular mail addressed to the undersigned as follows:

Notices shall be deemed to be received by the undersigned three (3) days following posting by The Pines.

This Guarantee and Indemnity shall be governed by and construed in accordance with the laws of the Cayman Islands.

Witness / Signature of Applicant
Print Name / Print Name
Date / Date

Rules of admission

THE PINES RETIREMENT HOME Rules of admission

  1. A person (the “Applicant”) wishing to make application for admission to The Pines Retirement Home (The “Pines”) is required to complete and sign the Application Form supplied by The Pines.
  1. The Applicant must be at least 55 years of age.
  1. The Applicant must have a physical examination by their private physician at the time of application.
  1. The Applicant cannot be accepted if his/her condition is such that a hospital-type care is required or if it is a mental condition that would require specialist treatment.
  1. After the Application Form has been received, a representative of The Pines will visit the Applicant at his/her home to discuss his/her application and to explain the current policy of The Pines in relation to admission and residency.
  1. The Pines will advise the Applicant, if considered suitable for admission to The Pines, of the security arrangements The Pines will, in its discretion, require to be put in place prior to admission to ensure payment of the fees due from time to time to The Pines from the Applicant (the “Residency Fees”).
  1. Unless there is an immediate vacancy the Applicant, if considered suitable for admission, will be placed on a waiting list until a vacancy occurs. Vacancies will be allocated to Applicants in the order Applicants appear on the waiting list. The admission of the Applicant will be conditional upon the Applicant remaining, in the opinion of The Pines, suitable for admission when a vacancy occurs. An Applicant who has been on the waiting list for one year or more must resubmit a new application.
  1. If a vacancy occurs and the Applicant wishes to defer admission the Applicant may, with the agreement of The Pines, reserve the vacant accommodation for such period and for such reservation fees as The Pines may determine.
  1. Prior to admission, The Pines will advise the Applicant of the residency Fees to be paid monthly in advance by the Applicant. The Applicant must pay the first month’s Residency Fees prior to admission plus a deposit (the “Deposit” is equivalent to one month’s Residency Fees).
  1. The Pines may at any time adopt addition or replacement admission policies, rules and requirements.

Acknowledged and agreed for on behalf of:
Name of Applicant (Print Name)
In the presence of:
Witness / Family Member or Signing Authority
Dated

Release of medical records

We, the next of kin of ______hereby give permission for the medical records to be released to the medical staff of The Pines Retirement Home as and when necessary.

DATED on this the ______day of ______, 20___

Address
Signed
Print Name

MEDICAL INFORMATION REPORT

Name: / Docket No:
Date of Birth: / CINICO No:
Date of medical record
Doctor providing record:
Next of Kin:
Relationship:
Next of Kin Contact Number (s)
Present medical conditions, with approximate dates of onset (including vital signs if appropriate):
Medical History:
Is patient HIV positive -Yes or No (please indicate):
Current medication(s):
Allergies:
Doctor’s Signature:
Print name:
Date:

Continue on a separate sheet if necessary

Daycare Admission Form (Revised 17th March 2014)Page 1 of 7