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Senior Residential Facility in Bedford, Ohio

APPLICATION Materials

Applicant’s Consent to Release Medical Information

I hereby authorize any physician, clinic or hospital to answer fully any request from Light of Hearts Villa for medical or psycho-social information concerning me as an applicant or while I am a Resident at Light of Hearts Villa.

"*" indicates required fields

Resident Name*
MM slash DD slash YYYY
MM slash DD slash YYYY

Application for Admission – Part 1

Emergency Contact Information
Resident Information

(Please Print)

First Name*
M.I*
Last Name*
Preferred Name/Nickname
MM slash DD slash YYYY
Gender*
Marital Status
CURRENT ADDRESS*
Primary Doctor
Name*
ADDRESS*
Other Doctor or Specialist
Name
ADDRESS
Dentist
Name*
ADDRESS*
Primary Hospital
Hospital Name*
ADDRESS*
Funeral Home
Funeral Home Name
ADDRESS
Other Doctors’ Notes and Contact Information:

Names & Relationship of Immediate Contact(s)

If there is a legal guardian, please list the information and attach documentation to this form.

Name of Guardian
ADDRESS
Power of Attorney

Contact #1 will be the first contacted in case of an Emergency.

Contact #1
Billable Party:*
Durable POA:*
Healthcare POA:*
Name:
ADDRESS
Contact #2
Billable Party:
Durable POA:
Healthcare POA:
Name:
ADDRESS
Contact #3
Billable Party:
Durable POA:
Healthcare POA:
Name:
ADDRESS

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NEWS & updates

Sister Regina Kusnir Chapel of Light: A Legacy of Faith and Compassion

December 17, 2024

Sister Regina Kusnir, SC, has lived a life of extraordinary charity and has been an integral part of Light of Hearts Villa. She helped coordinate the transition of Lumen Cordium High School into an assisted living facility in 1989. Since 2005, she has served as the director of pastoral and special ministries, where she helps address the spiritual life of residents.

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Light of Hearts Villa Celebrates 35th Anniversary, Raises Over $215,000 at Light the Way Gala

October 3, 2024

Over $215,000 was raised last week to help support the residents and community of Light of Hearts Villa, a Bedford-based nonprofit senior living facility, celebrating its milestone 35th anniversary at the Light the Way Gala. The event brought together 350 guests on September 27 to support of the Villa’s highly regarded, faith-based, compassionate care provided for older adults.

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283 Union Street | Bedford, Ohio 44146

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© 2024 Light Of Hearts Villa. All Rights Reserved. | Website by HLJ Creative
© 2024 Light Of Hearts Villa. All Rights Reserved. Website by HLJ Creative