Application Form

Please use the form below to apply online. A copy of your application will be forwarded to you if you choose to enter your email at the bottom.

If you would prefer to print and mail your application please use the appropriate application form (Pineview Manor Application , Country Garden Application , Sunrise Place Application) and submit completed application to:

Mennonite Nursing Home
Box 370
Rosthern, Saskatchewan
S0K 3R0

Online Application

Housing Options:

Pineview ManorCountry GardensSunrise Place

Suite you wish to be considered for:

Small SuiteLarge SuiteBoth

Occupancy:

Name in Full:

Email:

Phone Number:

Mailing Address:

Place of current residence:

Your Gender:

MaleFemale

Length of stay at your current residence:

From:

to:

If length of stay less than one year, give particulars of current residence

Date of Birth:

Place of Birth:

Marital Status:

Church Affiliation:

Name of Spouse:

Address of Spouse:

Name of Doctor:

Address of Doctor:

Doctor's Phone:

SK Health Services Number:

Are you now in hospital or special-care home?

YesNo

If yes, give name, address and date of admission:

Name of person who will act on your behalf in the event of an emergency:

Emergency Contact Relationship:

Emergency Contact Address:

Emergency Contact Phone:

List all of your next of kin, addresses, and phone numbers:

List all past major illnesses and surgeries:

Who, if anyone, has Power of Attorney:

Power of Attorney Phone:

Occupant #1

Occupant #2

Name in Full:

Email:

Phone Number:

Mailing Address:

Place of current residence:

Your Gender:

MaleFemale

Your Gender:

MaleFemale

Length of Stay:

From:

to:

If length of stay less than one year, give particulars of current residence

Date of Birth:

Place of Birth:

Marital Status:

Church Affiliation:

Name of Spouse:

Address of Spouse:

Name of Doctor:

Address of Doctor:

Doctor's Phone:

SK Health Services Number:

Are you now in hosital or special-care home?:

YesNo

Are you now in hosital or special-care home?:

YesNo

If yes, give name, address and date of admission:

Name of person who will act on your behalf in the event of an emergency:

Emergency Contact Relationship:

Emergency Contact Address:

Emergency Contact Phone:

List all of your next of kin, addresses, and phone numbers:

List all past major illnesses and surgeries:

Who, if anyone, has Power of Attorney:

Power of Attorney Phone:

Send me an Email:
Email Address:

YesNo

I hereby declare that I have completed this application form to the best of my knowledge. If accepted I will abide by the rules and regulations as set by the Board of Directors or Management. I also recognize that the Board of Directors will not be responsible in any way for any debts which I may incur.