Memory Care Housing Application – Boulder Creek

Complete the application form below and we will contact you.

Today's Date*
MM slash DD slash YYYY
My living accommodation preference:
- Resident Room A (360 sq ft)
- Resident Room B (440 sq ft)
Financial Information:*
- Private Pay
- Medical Assistance (EW / GRH)
Applicant's Name*
First Last
Date of Birth
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone*
Email
Contact Name
First Last
Address
Street Address City State ZIP Code
Phone
Email
Children's Name (if applicable)
Additional Information:
- Next Available
- Other
Conditions of the Priority List Agreement
1 – Your status on the Priority List is determined by your date of application, with earlier dates having higher priority. 2 – If you are notified of an open apartment that meets your preference and refuse, your date of application will be changed to the day of your refusal and therefore other names may pass you on the priority list. 3 – Prior to moving to Boulder Creek, applicants must complete an assessment by Stepping Stone Home Health. Boulder Creek reserves the right to determine if the community offers the appropriate level of care and services for the applicant.
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Conditions of the Priority List Agreement