286 Lion's Mouth Road
Amesbury, MA 01913
(978) 388-3752

15 Elizabeth Street
Amesbury, MA 01913
(978) 388-0293

Application for Residency


Thank you for your expression of interest in residency at The Elizabeth Calsey House/Elizabeth Calsey House at Lionís Mouth Road. Please complete the application below. We will contact you shortly after. Thank you.

Please Note: There is a $1,000 Administrative/Assessment fee due upon completion of the Residency Agreement. This fee is not a deposit of any kind and is not applied toward any charges in connection with residency at E.C.H.



GENERAL INFORMATION






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CONTACT INFORMATION











CURRENT LIVING SITUATION





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HEALTH CARE INFORMATION








DAILY LIVING


Bathing
Dressing
Shaving/Grooming
Medication Reminders
Housekeeping
Laundry
Toileting
Escort/Mobility
Night Care








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I understand and agree that this application is neither a contract, nor a reservation for residency. Nothing contained in this document obligates or entitles me to a room at the Elizabeth Calsey House until a Residency Agreement has been signed by all parties involved.



MOVE-IN/MOVE-OUT IS SCHEDULED BETWEEN 9 A.M. AND 3 P.M. MONDAY THROUGH FRIDAY UNLESS OTHERWISE GRANTED.

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