Independent Living Form | Stuarts Draft Retirement Community

Applicant Information

First Name

Last Name

Date of Birth

Second Applicant First Name (if applicable)

Second Applicant Last Name

Date of Birth

Mailing Address (street, route, or box no.)

City

State

Zip Code

Telephone No.

Email Address

Marital Status

Single Married Divorced Widowed

Emergency Contact Name

Emergency Contact Telephone No.

About You

Health Status (list any serious illnesses or chronic physical problems you or your spouse may have)

Hobbies, Pastimes, Social Interests, Talents, etc.

Former Occupation(s)

Religious Affiliation (optional)

Desired Date of Occupancy

Residence Preferences

Rank up to three choices across any of the options below (1st, 2nd, and 3rd choice).

Villas
Blue Ridge — 1 bedroom, 650 sq. ft.
Augusta — 2 bedrooms, 850 sq. ft.
Virginian — 2 bedrooms, 2 bathrooms, 1,300 sq. ft.
Garage (if available) for Blue Ridge / Augusta

Skyline Terrace
Unit A: The Woodland — Efficiency
Unit B: The Magnolia — 1 bedroom, 1 bath
Unit C: The Dogwood — 2 bedrooms, 1 bath
Level preference for Skyline Terrace

Shenandoah Terrace
The Washington — 1 bedroom, 1 full bath
The Monroe — 1 bedroom, 1 full bath
The Jefferson — 2 bedrooms, 1½ baths
The Wilson — 2 bedrooms, 2 full baths
The Madison — 2 bedrooms, 2 full baths
Level preference for Shenandoah Terrace

Waiting List & Deposit

A non-refundable deposit of $1,000.00 is required to be placed on the waiting list, first priority. This deposit is applied toward the security deposit at move-in. A one-month security deposit is required at lease signing. Apartments are available for lease on a 12-month contract basis. There is no entry fee. All residents are subject to the rules and regulations of the facility.

I am submitting a deposit in the amount of $1,000.00 to be placed on the first priority waiting list. I am NOT submitting a deposit, but wish to be on the general waiting list for an independent living unit in the future.

Acknowledgment

Applicant Name (type your full name in lieu of a signature)

Date

Second Applicant Name (if applicable)

Date

I acknowledge that typing my name above serves as my signature, that the information provided in this application is accurate to the best of my knowledge, and that all residents are subject to the rules and regulations of the facility.

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