Common use of Application for Admission Clause in Contracts

Application for Admission. The Jewish Home of Rochester (JHR) adheres to kosher dietary laws and Passover dietary observance. Therefore, anyone admitted is informed of and agrees to comply with the laws of ▇▇▇▇▇▇▇▇. Kosher meals served at the Jewish Home do not mix milk and meat at the same time. Pork, pork products, and shellfish are not served. Additionally, during the eight-day Passover Holiday, only specially prepared kosher foods are served. Name: Maiden Name: Last First MI Address: City State Zip Telephone: County of Residence: Sex: Marital Status: ( )Married ( )Widow ( )Single ( )Separated ( )Divorced Current Location: At home: ( )Yes ( )No If no, Name of Hospital: Name of Nursing Home or Assisted Living Facility Birthdate: Birthplace: Age: Name of Spouse: If deceased when? U.S. Citizen: ( )Yes ( )No - If NOT a Citizen, do you have a Permanent Visa? Year Permanent Visa Obtained: Religion: Jewish Catholic Protestant Other Name of Synagogue or Church: Are either you or your spouse a United States Veteran? ( )Yes ( )No Have you ever been a Resident of the JHR? ( )Yes ( )No Have you ever been a Participant of the Day Services at the JHR? ( )Yes ( )No Have you ever been a Resident of ▇▇▇▇ Manor? ( )Yes ( )No *This completed application and a PRI (Patient Review Instrument) must be submitted to the Jewish Home of Rochester before an individual can be considered for admission. Submission of such an application does not create automatic entitlement to admission, or mean that the applicant will automatically be placed in the Home’s waiting pool. Placement in the waiting pool is made after an application is fully reviewed and approved.

Application for Admission. Date received: The Jewish Home of Rochester (JHR) adheres to kosher dietary laws and Passover dietary observance. Therefore, anyone admitted is informed of and agrees to comply with the laws of ▇▇▇▇▇▇▇▇. Kosher meals served at the Jewish Home do not mix milk and meat at the same time. Pork, pork products, and shellfish are not served. Additionally, during the eight-day Passover Holiday, only specially prepared kosher foods are served. Name: Last First MI Maiden Name: Last First MI Address: City State Zip Telephone: County of Residence: Sex: Marital Status: ( )Married ( )Widow ( )Single ( )Separated ( )Divorced Current Location: At home: ( )Yes ( )No If no, Name of Hospital: Name of Nursing Home or Assisted Living Facility Birthdate: Birthplace: Age: Name of Spouse: If deceased when? U.S. Citizen: ( )Yes ( )No - If NOT a Citizen, do you have a Permanent Visa? Year Permanent Visa Obtained: Religion: Jewish Catholic Protestant Other Name of Synagogue or Church: Are either you or your spouse a United States Veteran? ( )Yes ( )No Have you ever been a Resident of the JHR? ( )Yes ( )No Have you ever been a Participant of the Day Services at the JHR? ( )Yes ( )No Have you ever been a Resident of ▇▇▇▇ Manor? ( )Yes ( )No *This completed application and a PRI (Patient Review Instrument) must be submitted to the Jewish Home of Rochester before an individual can be considered for admission. Submission of such an application does not create automatic entitlement to admission, or mean that the applicant will automatically be placed in the Home’s waiting pool. Placement in the waiting pool is made after an application is fully reviewed and approved.