10. Admission Agreement Disclosure

ADMISSION AGREEMENT DISCLOSURE

Tile 4, Chapter 33. 408 B. NCIA Board

House *
Select
Select
Hayden
McDonald
Paradise Valley
Sunnyvale
SUNRISE CARE HOMES (SCH) have informed,

Resident Representative, Legal Guardian *

who is the Resident, Resident Representative, Legal Guardian for

Resident Name *

SCH will pay or has paid a one time referral fee of $

One time referral fee *

Referral of *

for the referral of , should this resident be placed at this home.

The referral agency/representative does not have any ownership interest in this adult care home and this adult care home does not have any ownership interest in the referral agency.
Signature will acknowledge that the resident has been acknowledged of this information prior or at the time of the placement.

Resident or Representative Signature *

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Date *