Application Form

(For Senior Citizens Seeking Residential Care)

Applicant Name*

Gender*

Male

Female

Transgender

Marital Status

Single

Married

Widowed

Divorced

Address*

Phone Number*

Applicant Aadhar Number*

Guardian Name*

Guardian Present Address*

Guardian Parmanent Address*

Guardian Aadhar Number*

Guardian Email*

Emergency Contact 1*

Emergency Contact 2*

Financial Responsibility (If applicable)

Yes

No

Preferences and Requirements*

Day Care

Respite Care

Short Term Stay

Long Term Assisted Living

Declaration - I hereby declare that the information provided above is true and complete to the best of my knowledge. I understand that admission is subject to the policies and assessment procedures of Ashraya Foundation.*

I agree

I disagree

Application Form

MISSION

Donations to ASHRAYA FOUNDATION are exempted under section 80G of Income Tax Act.