Intake Application Form

Apply for residency at Mara Place Residence

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Health Card Number Format: 1234-123-123-XX

Health Card Expiry

Contact & Address

Street Address *

City *

Province *

Postal Code * Format: A1A 1A1

Phone Auto-formatted

Mobile * Auto-formatted

Email Address *

Medical Information

Diagnosis / Medical Conditions *

Dietary Requirements / Restrictions

Family Doctor Name & Address

Specialist Doctor Name

Specialist Doctor Address

Emergency Contact / Decision Maker

Full Name *

Relationship to Applicant *

Street Address

City

Province

Postal Code

Phone

Mobile

Additional Information

Who is the primary decision maker? *

Preferred Identification Name (PIN) or Nickname

Eye Color

Private or Semi-Private Room Preference

Spam Verification

Slide to verify you're not a robot

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I agree to the terms and conditions *

By submitting this application, I certify that all information provided is accurate and complete. I understand that Mara Place Residence may contact me for verification purposes. I agree to the privacy policy and terms of service regarding the handling of my personal information.

Fields marked with * are required.