Resident Admission Agreement

Assisted Living Facility Name:
Facility Address: Unit # Zip:
Phone:  Email:

Date of Admission:
Resident Name:
Date of Birth: Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberDay12345678910111213141516171819202122232425262728293031Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035
Social Security Number:
Responsible Party (if applicable):
Relationship to Resident:
Phone: | Email:

1. Purpose of Agreement

This Resident Admission Agreement ("Agreement") establishes the terms and conditions under which the Resident will be admitted and receive services at the Assisted Living Facility ("Facility").

2. Services Provided

The Facility shall provide the following services to the Resident:

• 24-hour supervision and assistance

• Assistance with activities of daily living (ADLs) such as bathing, dressing, and mobility

• Medication management

• Housekeeping and laundry services

• Meal preparation and dietary accommodations

• Social and recreational activities

• Transportation assistance

3. Residency Requirements

To qualify for residency at the Facility, the Resident must:

• Be at least years of age

• Require assistance with daily living activities.

• Not require continuous skilled nursing care.

• Be free from communicable diseases.

• Adhere to the Facility’s policies and regulations

4. Fees and Payment Terms

4.1 Monthly Fees

The Resident agrees to pay the following:

• Base Monthly Rent: $

• Additional Service Fees (if applicable): $

• Security Deposit: $

• One-time Admission Fee: $

4.2 Payment Schedule

• Payments are due on the day of each month.

• Late fees of $ will be assessed if payment is not received by the day of the month.

• Payments shall be made via [Check/Credit Card/Bank Transfer].

4.3 Refunds and Adjustments

• The Facility will provide a prorated refund if the Resident vacates the premises mid-month.

• Deposits may be refundable subject to the terms outlined in Section 7.

5. Resident Rights and Responsibilities

5.1 Resident Rights

The Resident has the right to:

• Dignity, privacy, and respect

• Participate in social and recreational activities.

• Receive medical care from a provider of their choice.

• Voice concerns or complaints without retaliation

• Have visitors during designated hours.

• Confidentiality of personal and medical information

5.2 Resident Responsibilities

The Resident agrees to:

• Comply with Facility rules and regulations.

• Maintain personal hygiene and cleanliness.

• Notify Facility staff of any medical changes.

• Respect the rights and property of others

6. Termination of Residency

The Facility reserves the right to terminate residency under the following conditions:

• Non-payment of fees for more than days

• Violation of Facility Policie

• Determination that the Resident requires a higher level of care

• The Resident poses a risk to themselves or others

7. Security Deposit Policy

• Security deposits will be refunded within days after the Resident vacates the premises.

• Deductions may be made for unpaid fees, damages, or cleaning costs beyond normal wear and tear.

8. Emergency and Medical Care

• The Facility shall provide emergency response services but does not provide skilled nursing care.

• In case of a medical emergency, the Resident will be transported to the nearest hospital at their own expense.

• The Resident is responsible for all medical costs not covered by insurance.

9. Visitation Policy

• Visiting hours are from AM to PM daily.

• Visitors must check in at the front desk and adhere to Facility policies.

• Overnight visitors are not permitted without prior approval.

10. Insurance and Liability

• The Facility carries general liability insurance but is not responsible for lost, stolen, or damaged personal property.

• The Resident is encouraged to obtain personal insurance coverage.

11. Changes to Agreement

• The Facility reserves the right to modify this Agreement with a __-day notice.

• The Resident will be informed of any changes in services, fees, or policies.

12. Acknowledgment and Signatures

By signing below, the parties acknowledge that they have read and understand this Agreement and agree to its terms.

Resident Name:
Resident Signature:

Responsible Party Name (if applicable):
Responsible Party Signature:

Facility Representative Name:
Facility Representative Signature:

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