Name:__________Move In Date:__________
Nickname or How Resident Prefers to be Addressed:__________
Date and Place of Birth:__________
Religious Preference__________Church Attended:__________
Does Resident have hearing or vision deficits:__________
Educational History:__________
Occupation:__________
Family History:
Spouse Name:__________Years Married:__________
Number of Children and Names:__________
Number of Grandchildren and Great Grandchildren and Names if possible:
Sisters or Brothers and Names:
Military Background:
Are you a veteran yes/no__________
Are you a spouse of a veteran?__________
What branch of service/dates of service and where served/rank
American House has a Wall of Honor. Could we display your picture to be recognized. Any pertinent info you would like to share about your time of service.
What are your past and current interests?
Have you volunteered/where and would you like to be a resident volunteer?
