Residential Living Center Registration Application

Name and Location of Center
Do you have a DBA (Doing Business As)?
Contact Information
Primary Contact
Physical Address
Center Capacity and Services

Residential services offered or furnished:

Limited assistance with eating, bathing, and dressing?
Limited assistance with personal and household chores?
Organized social and recreational activities?
Transportation services?
Limited assistance with self-administration of medications?
Monitoring of nutrition or health?
Protective supervision necessary to prevent posing a health or safety hazard to self or others?

Individuals residing in a residential living center must be independent, able to respond appropriately in the event of a fire or other unsafe situations, able to self-administer medications and able to self-direct their own daily activities. Limited assistance may be provided for those residents who need help cutting up meat, transferring into the tub or shower safely, buttoning a shirt, or opening up a medication bottle. Refer to the Residential Living Center Resident Evaluation for further information.