The Oberon 9160 West 64th Avenue Arvada, CO 80004 (303) 420-7258 FAX# 420-1799 Application for Residence Name of Applicant:_____________________________ Date Applied:________________________ Current Address:__________________________________________________________________ Telephone Number:_____________ Date of Birth:________________ Male or Female (Please circle one) Will you be Private Pay or Medicaid? (Please circle one) Person to contact regarding this application:_________________________ Telephone: Work:_____________ Home:_____________ Mailing Address:__________________________________________________________________ Please describe the applicant's current living situation and functional status: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Physician's Name & Tele#:__________________________________________________________ Insurance Company and Policy#:______________________________________________________ How did you hear of the Oberon?:_____________________________________________________ Religious Preference & Church:_______________________________________________________ Please tell us more about your current lifestyle: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ As a family member, would you be interested in either volunteering or working at the Oberon? (Please circle one) Please complete and return to the above address. Thank you for your interest.