{"id":15,"date":"2015-03-05T23:05:36","date_gmt":"2015-03-05T23:05:36","guid":{"rendered":"https:\/\/evansresidentialcare.com\/?page_id=15"},"modified":"2025-07-31T23:17:42","modified_gmt":"2025-07-31T23:17:42","slug":"registration-requirements","status":"publish","type":"page","link":"https:\/\/evansresidentialcare.com\/?page_id=15","title":{"rendered":"Application"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Please fill out the form below and you will be contacted shortly.<\/p>\n\n\n<style id=\"wpforms-css-vars-2589\">\n\t\t\t\t#wpforms-2589 {\n\t\t\t\t--wpforms-container-padding: 0px;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-radius: 3px;\n--wpforms-background-color: rgba(0, 0, 0, 0);\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-2589\"><form id=\"wpforms-form-2589\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2589\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F15\" data-token=\"cf358ffe2b335a7f5a461999f4eaa456\" data-token-time=\"1786266901\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-2589-field_4-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth wpforms-first\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-2589-field_4\">Care Recipient<\/label><input type=\"text\" id=\"wpforms-2589-field_4\" class=\"wpforms-field-small\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-2589-field_4-error\" aria-describedby=\"wpforms-2589-field_4-description\" ><div id=\"wpforms-2589-field_4-description\" class=\"wpforms-field-description\">Prefix<\/div><\/div><div id=\"wpforms-2589-field_6-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-2589-field_6\">  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2589-field_6\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-2589-field_6-error\" aria-describedby=\"wpforms-2589-field_6-description\" required><div id=\"wpforms-2589-field_6-description\" class=\"wpforms-field-description\">First<\/div><\/div><div id=\"wpforms-2589-field_7-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-2589-field_7\">  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2589-field_7\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-2589-field_7-error\" aria-describedby=\"wpforms-2589-field_7-description\" required><div id=\"wpforms-2589-field_7-description\" class=\"wpforms-field-description\">Last<\/div><\/div><div id=\"wpforms-2589-field_8-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-2589-field_8\"> <\/label><input type=\"text\" id=\"wpforms-2589-field_8\" class=\"wpforms-field-small\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-2589-field_8-error\" aria-describedby=\"wpforms-2589-field_8-description\" ><div id=\"wpforms-2589-field_8-description\" class=\"wpforms-field-description\">Suffix<\/div><\/div><div id=\"wpforms-2589-field_5-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-2589-field_5\">Phone<\/label><input type=\"text\" id=\"wpforms-2589-field_5\" class=\"wpforms-field-large\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-2589-field_5-error\" ><\/div><div id=\"wpforms-2589-field_2-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-2589-field_2\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2589-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" spellcheck=\"false\" aria-errormessage=\"wpforms-2589-field_2-error\" required><\/div><div id=\"wpforms-2589-field_11-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Current living situation of care recipient<\/legend><ul id=\"wpforms-2589-field_11\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_11_1\" name=\"wpforms[fields][11][]\" value=\"Lives in own home\" aria-errormessage=\"wpforms-2589-field_11_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_11_1\">Lives in own home<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_11_2\" name=\"wpforms[fields][11][]\" value=\"Senior apartment\" aria-errormessage=\"wpforms-2589-field_11_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_11_2\">Senior apartment<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_11_3\" name=\"wpforms[fields][11][]\" value=\"Nursing home\" aria-errormessage=\"wpforms-2589-field_11_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_11_3\">Nursing home<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_11_4\" name=\"wpforms[fields][11][]\" value=\"Assisted living facility\" aria-errormessage=\"wpforms-2589-field_11_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_11_4\">Assisted living facility<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_11_6\" name=\"wpforms[fields][11][]\" value=\"With family member\" aria-errormessage=\"wpforms-2589-field_11_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_11_6\">With family member<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_11_7\" name=\"wpforms[fields][11][]\" value=\"Currently hospitalized\" aria-errormessage=\"wpforms-2589-field_11_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_11_7\">Currently hospitalized<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2589-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-2589-field_12\">Address associated with the Care Recipient<\/label><input type=\"text\" id=\"wpforms-2589-field_12\" class=\"wpforms-field-large\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-2589-field_12-error\" aria-describedby=\"wpforms-2589-field_12-description\" ><div id=\"wpforms-2589-field_12-description\" class=\"wpforms-field-description\">Street Address<\/div><\/div><div id=\"wpforms-2589-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-2589-field_13\" aria-hidden=\"false\">Address Line 2<\/label><input type=\"text\" id=\"wpforms-2589-field_13\" class=\"wpforms-field-large\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-2589-field_13-error\" aria-describedby=\"wpforms-2589-field_13-description\" ><div id=\"wpforms-2589-field_13-description\" class=\"wpforms-field-description\">Address Line 2<\/div><\/div><div id=\"wpforms-2589-field_15-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"15\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-2589-field_15\" aria-hidden=\"false\">City<\/label><input type=\"text\" id=\"wpforms-2589-field_15\" class=\"wpforms-field-large\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-2589-field_15-error\" aria-describedby=\"wpforms-2589-field_15-description\" ><div id=\"wpforms-2589-field_15-description\" class=\"wpforms-field-description\">City<\/div><\/div>\t\t<div id=\"wpforms-2589-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-2589-field_1\" >Country Care Phone<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-2589-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-2589-field_14-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"14\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-2589-field_14\" aria-hidden=\"false\">State<\/label><input type=\"text\" id=\"wpforms-2589-field_14\" class=\"wpforms-field-large\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-2589-field_14-error\" aria-describedby=\"wpforms-2589-field_14-description\" ><div id=\"wpforms-2589-field_14-description\" class=\"wpforms-field-description\">State \/ Province \/ Region<\/div><\/div><div id=\"wpforms-2589-field_16-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"16\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-2589-field_16\" aria-hidden=\"false\">Country<\/label><input type=\"text\" id=\"wpforms-2589-field_16\" class=\"wpforms-field-large\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-2589-field_16-error\" aria-describedby=\"wpforms-2589-field_16-description\" ><div id=\"wpforms-2589-field_16-description\" class=\"wpforms-field-description\">Country<\/div><\/div><div id=\"wpforms-2589-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Service Specifications<\/legend><ul id=\"wpforms-2589-field_17\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Bathing\/Hygiene\" aria-errormessage=\"wpforms-2589-field_17_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_1\">Bathing\/Hygiene<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_2\" name=\"wpforms[fields][17][]\" value=\"Lift\/Transfers\" aria-errormessage=\"wpforms-2589-field_17_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_2\">Lift\/Transfers<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_3\" name=\"wpforms[fields][17][]\" value=\"Safety supervision\" aria-errormessage=\"wpforms-2589-field_17_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_3\">Safety supervision<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_4\" name=\"wpforms[fields][17][]\" value=\"Ambulation \/ Assist with walking\" aria-errormessage=\"wpforms-2589-field_17_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_4\">Ambulation \/ Assist with walking<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_6\" name=\"wpforms[fields][17][]\" value=\"Transportation to medical appointments\" aria-errormessage=\"wpforms-2589-field_17_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_6\">Transportation to medical appointments<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_7\" name=\"wpforms[fields][17][]\" value=\"Feeding tube\" aria-errormessage=\"wpforms-2589-field_17_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_7\">Feeding tube<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_9\" name=\"wpforms[fields][17][]\" value=\"Alzhiemer&#039;s\/Dementia\" aria-errormessage=\"wpforms-2589-field_17_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_9\">Alzhiemer's\/Dementia<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_10\" name=\"wpforms[fields][17][]\" value=\"Eating assistance\" aria-errormessage=\"wpforms-2589-field_17_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_10\">Eating assistance<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_11\" name=\"wpforms[fields][17][]\" value=\"Dressing \/ Grooming\" aria-errormessage=\"wpforms-2589-field_17_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_11\">Dressing \/ Grooming<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-2589-field_17_12\" name=\"wpforms[fields][17][]\" value=\"Medication reminder\" aria-errormessage=\"wpforms-2589-field_17_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2589-field_17_12\">Medication reminder<\/label><\/li><\/ul><\/fieldset><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-2589-field_1-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-2589-field_1-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-2589-field_1-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2589\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/evansresidentialcare.com\/index.php?rest_route=\/wp\/v2\/pages\/15\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2589\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/evansresidentialcare.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; Please fill out the form below and you will be contacted 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