Resident Application - Highland Oaks of Elgin

Thank you for your interest in Apostolic Christian Highland Oaks. We ask that you please complete this application as the first step to our admission process. The remaining steps include an interview with the prospective resident and/or family representative, assessment of the prospective resident by Highland Oaks staff, and completion of the Admission Application Packet. During this admission process it will be determined if the best interest of the resident and Highland Oaks would be served by admitting the prospective resident to our facility.

If this placement is for Private-Pay, Long-Term Care, please click the following link to completed the full Admission Application Packet: Resident Application

Applicant Information

Applicant Name (required)

Applicant Age

Applicant Marital Status

Current Living Arrangements (required)

Please describe

Time of Placement (required)

Please describe

Living Option (required)

Applicant Financial Information

Approximate Financial Accounts Total of Applicant (required) Checking, savings, CDs, stocks, etc

Approximate Real Estate Net Worth of Applicant (required) Value of home minus amount owed

Approximate Monthly Income of Applicant (required) Social Security, pensions, annuities, etc

Does Applicant have Long Term Care Insurance?
YesNo

Approximate Daily Long Term Care Insurance (required)

Contact Information

Name (required)

Phone (required)

Email (required)

How Would You Prefer to be Contacted?
PhoneEmail

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