OSCR Residential Tower Application
Applicant Information
Title
*
First Name
Middle Name
*
Last Name
Preferred Name
Personal Pronouns
Gender
Select all that apply
Marital Status
Cultural or ethnic heritage:
*
Date of Birth:
*
Email
Confirmation messages will be sent to this address
*
Primary Phone
Secondary Phone
Main spoken language
English
French
Sign Language
Other
Citizenship Status
Social Insurance Number
Street Address
Unit
City
Postal Code
How long have you lived at this address?
Current Living Arrangement
Current monthly rent/ mortgage costs
Emergency Contact Information
*
First Name
*
Last Name
*
Relationship to Applicant
*
Primary Phone
*
Add a secondary emergency contact?
Yes
No
*
Do you give us permission to speak with your emergency contact(s) about your application?
Yes
No
Residence Application Information
*
How did you hear about Oakville Senior Citizens Residence?
*
Have you toured or visited OSCR?
What style of unit are you interested in?
When would you be looking to move in?
Level of Care
Please check all that apply to you. You may be asked to provide more information depending on your answer.
Are you able to direct your own care?
Yes
No
Do you have family/caregiver/friend that assists you in any other areas of care or support?
Yes
No
Do you require 24-hour care?
Yes
No
Do you have a visiting healthcare professional?
e.g., a nurse, doctor, physiotherapist
Yes
No
Are you accessing other services?
i.e. Links2Care, Meals on Wheels, Emergency Response System, CNIB, etc.
Yes
No
Do you require assistance with a bath/ shower?
Yes
No
Do you require help with daily activities?
For example, getting in or out of bed, toileting, etc.
Yes
No
Do you require assistance with getting dressed and undressed?
Yes
No
Do you require assistance with being reminded to take your medications?
Yes
No
Do you require assistance with making meals?
For example, meal preparation, grocery shopping, operating your stove, etc.
Yes
No
Do you use a walker?
Do you use a wheelchair?
Do you use a scooter?
Do you sometimes fall?
Yes
No
Do you sometimes feel isolated, lonely or afraid?
Yes
No
Do you have other areas of need?
Yes
No
Over the past year, how many days have you been hospitalized?
Financial Information
*
Old Age Security (OAS)
If not applicable, enter N/A
*
Canada Pension Plan (CPP)
If not applicable, enter N/A
*
Other Income Source
If not applicable, enter N/A
Documentation
Please include the following documents with your application. You may upload a copy to this form, or you may send a copy by mail.
A copy of a legal document showing your status in Canada
e.g., Passport, Birth Certificate, Certificate of Indian Status, Canadian Permanent Resident Card, etc.
I will mail a copy
I will upload a copy
A copy of your most recent Notice of Assessment
I will mail a copy
I will upload a copy
Consent
Read more details about consent to send this application to Oakville Senior Citizens Residence
By clicking "Submit", you agree to send this personal information to Oakville Senior Citizens Residence online. You agree to these
Terms and Conditions
and
Privacy Policy
, which govern how your personal information is kept safe.
Submit
