Independent Living Declaration

Independent Living Declaration (required for residency)

Reviewed and Approved as Independent Living Requirements by Board for Stipend Fund 2.7.18;

Approved by Board for All Applicants for Residency as Independent Living Requirements 10.30.20

Approved by Board as Independent Living Declaration 03.01.21

A private, non profit facility, Alder Springs Deaf & Blind Community is an independent living apartment community open to all people able to satisfactorily demonstrate the ability to live independently when they apply for residency and throughout their residency at Alder Springs. At any time during residency, the Board of Directors may request an updated Independent Living Declaration.

The ability to live independently is one of the requirements necessary for an applicant to be approved for residency. Alder Springs does not have an on site supervisor or employee and does not provide care or services to residents.

The Alder Springs Board of Directors utilizes non-family references and this Independent Living Declaration to determine at any time to its satisfaction an applicant’s/resident’s ability to live independently. Additional consideration is given to Blind and Deafblind applicants/residents.

The Alder Springs Board of Directors reserves the sole right to make the final determination in all matters related to an applicant’s/resident’s ability to live independently.

Guidelines for Independent Daily Living

Applicant/Resident should check each item below to indicate agreement

Approved Assistance Providers should write and initial comments beneath any item.

___ Ability to live alone including with qualified assistance as approved by Alder Springs

___ Ability and willingness to consistently follow all the Rules & Regulations and Residential Rental Contract provisions

___ Ability and willingness to follow all the requirements of approved qualified assistance persons/agencies

___ Ability to live agreeably in a peaceful, secure community of peers and to respect the privacy and peace of other residents and their visitors at Alder Springs

___ Ability to responsibly and reliably manage financial needs and demands including with the assistance of persons approved by Alder Springs

___ Willingness to provide and update a complete list of names and contact information of all persons/agencies who provide assistance

___ Ability to manage daily health needs including medications, medical regimens, etc.

___ Ability to plan and serve adequate meals daily

___ Ability to take care of all shopping needs

___ Ability to utilize telephonic/electronic communications devices without assistance

___ Willingness to utilize the Resident Portal feature of the Alder Springs website

___ Ability to provide for all transportation needs

___ Ability to “keep house” and manage laundry needs

Applicant Independent Living Declaration (each applicant/resident must complete separately)

I, the undersigned applicant/resident of Alder Springs, understand and agree that other qualified persons (Approved Assistance Provider) may be asked to complete this document as it relates to me and I also agree that subsequent board approved changes in the stipulations of the Independent Living Declaration are applicable to me.

By the signature(s) below, each signer declares they have read this Declaration and declares that applicant/resident in question can live independently in accordance with this Declaration. Each signer declares that for the prior 12 months the applicant/resident has lived independently in accordance with this Declaration.

_______________________________________________________ _______________

Signature of Resident Date

_______________________________________________________ _______________

Signature of Approved Assistance Provider Date

Non Family References

Each applicant/resident must provide three non family references with a phone number and email address for each. This Independent Living Declaration is incomplete without the required Non Family References.

Name __________________________________________________________________________________

Phone ________________________________ Email __________________________________________

Name __________________________________________________________________________________

Phone ________________________________ Email __________________________________________

Name __________________________________________________________________________________

Phone ________________________________ Email __________________________________________