Application for Admission to Redstone Highlands (Page 1 of 3)
All questions must be answered in order to be considered for admission.



Full Name*
Address 1*
Address 2
City*
State*
Zip Code*
Telephone*
Birthdate*
Presently Residing*
If Other, Please Describe
Occupation
Marital Status*
Name of Spouse
Spouse's Birthdate
Spouse's Occupation

Name and residence of Children, Relatives, Responsible Party, Power of Attorney, Executor of Will to be contacted in an emergency

Contact #1
Name*
Relationship*
Address*
Telephone*

Contact #2
Name
Relationship
Address
Telephone

Contact #3
Name
Relationship
Address
Telephone

Financial Power of Attorney
Name*
Relationship* Financial Power of Attorney
Address*
Telephone*

Healthcare Power of Attorney
Name*
Relationship* Healthcare Power of Attorney
Address*
Telephone*

A copy of Power of Attorney, insurance cards and Social Security card will be required prior to move-in.

Will you bring a car? *
Will you bring a pet?*
(applicable to apartment residents only)
If yes, what kind of pet?
Do you smoke?*
Smoking at Redstone is limited to DESIGNATED AREAS and apartments only.

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