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OUR HOMES
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- Residency Application
- Employment Application
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Residency Application

Submit our 2-page form below OR
download the PDF version and mail to:

Resident Application

ElderCare Network of Lincoln County

P.O. Box 652

Damariscotta, ME 04543

Personal Information

Name*

Phone #

Social Security #*

Birthday

Month

Day

Year

Marital Status

Single

Married

Widowed

Separated/Divorced

Current Address

Current Living Arrangement

Independent

With Family/ Friends

Boarding Home

Nursing Home

Waiting in Hospital

Other

Preference

Primary reason for interest in one of our facilities*

Projected Date of Move

Desired Location

Edgecomb

Jefferson

Damariscotta

Round Pond

Waldoboro

Insurance

MaineCare #

MediCare #

MediCare Part D Plan and #

Other Medical Insurance

Health Information

Physician

Physician's Address

Medical diagnoses

Any Mental health or behavioral problems?

Medications

Special Dietary Needs

Special Medical Needs (i.e. oxygen, injections, catheter)

Level of mobility (single-floor)

Independent

Wheelchair

Walker

Cane

Other

Can applicant navigate stairs comfortably?

Yes

No

OUR HOMES

Hodgdon Green

Edgecomb Green

Jefferson Green

Round Pond Green

Waldoboro Green

APPLY

Residential application

Employment application

GIVE BACK

Volunteer

Donate

Send a letter

CONTACT

ADMISSIONS

Dianna Leeman
207-563-2148 x2

ACCOUNTS PAYABLE

Patricia Holbrook

207-563-2148 x4

OFFICE

Nancy Marcille
207-563-2148 x3

Designed by S. Hinman Design

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