Retirement Home & Assisted Living Signup

Full Name

Age

Gender

Phone Number

Email Address

HEALTH BACKGROUND

Known medical conditions or diagnoses

Known Allergies

Level of Mobility

Assistance needed with daily activities

Dietary requirement or preferences

FINANCIAL SPONSOR/NEXT OF KIN
This is the person responsible for the resident's financial obligations and who will be the primary contact for the Foundation. If there are multiple parties, please provide the lead contact.

Full name

Relationship to resident

Resident address

Primary phone number

Alternative phone number

Email address

Occupation/ profession

FINANCIAL DETAILS

Preferred payment method

Preferred billing cycle

Are you the sole financial sponsor for this resident?

Yes, I am the sole sponsor No, costs are shared

Authorisation to receive invoices and billing notices

Yes, send all billing correspondence to me Send to a different contact

Are you currently residing in Nigeria?

Yes No, I am in the diaspora

EMERGENCY CONTACT
If different from the financial sponsor above, provide a person reachable in case of an urgent medical or care situation.

Full name

Relationship to resident

Phone number

Email address

Preferred facility location

Anticipated admission date

How did you hear about Rosehope Foundation?

Additional Notes, questions, or special requests

DECLARATION

Declaration

I understand that submission of this form does not constitute a formal admission offer, and that admission is subject to assessment and availability.

I consent to Rosehope Foundation contacting me via the details provided to discuss this enquiry.

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