schedule a tour | DONATE

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
Clear Signature
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

Where to begin

Giving

ways to give
why give
naming opportunities
memorial gifts
GIVE NOW

NEWS & updates

Summer at the Villa Family Social

June 29, 2026

Come enjoy a relaxing summer evening with delicious food and refreshments, beautiful gardens, and great company. Whether you’re visiting a loved one, reconnecting with friends, or learning about our community for the first time, we look forward to welcoming you.

KEEP READING

Reflecting on the Compassion of Sister Miriam Erb: Jennifer Grogan’s CSA Story

June 29, 2026

As the Sisters of Charity of St. Augustine celebrate 175 years of serving others, we’re honored to share stories from those whose lives have been touched by their mission. For Jennifer Grogan, assistant dietary director at Light of Hearts Villa, working alongside the Sisters has been a powerful reminder of what it means to lead with compassion, serve with humility, and care for others with unwavering grace.

KEEP READING
View all