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Located in North Carolina, we provide exceptional senior care services, ensuring safety, comfort, and a fulfilling lifestyle for residents.

Call us +1 919-933-9570

admin@gracefullivingalf.com

 

Become A Member

Graceful Living Assisted Living Facility / Become A Member

    1. Personal Information

    Full Name: Date of Birth: Gender: Marital Status: Phone Number: Email Address: Home Address:

    2. Emergency Contact Information

    Primary Emergency Contact Name: Relationship to Applicant: Phone Number: Secondary Emergency Contact Name (Optional): Relationship to Applicant: Phone Number:

    3. Medical Information

    Primary Physician Name: Physician Contact Number: Known Medical Conditions: Allergies (if any): Current Medications: Mobility Status (Check one):

    4. Living & Care Preferences

    Preferred Room Type (Check one):
    Dietary Restrictions or Preferences: Assistance Needed (Check all that apply): BathingDressingMedication ManagementHousekeepingTransportation

    5. Financial & Insurance Details

    Preferred Payment Method (Check one): Insurance Provider (if applicable): Policy Number:

    6. Additional Information

    Hobbies & Interests: Religious or Cultural Preferences: Do you have a legal guardian or power of attorney? Any additional notes or special requests?

    7. Declaration & Consent

    I hereby declare that the information provided is accurate and complete to the best of my knowledge. I consent to the terms and conditions of the assisted living facility. I authorize medical assistance and emergency care if needed. Signature of Applicant or Guardian: Date: Facility Representative Signature: Date: