Southern Vacation Stay Application

Please complete and return this Application for a Franke At Seaside Vacation Stay. This information is kept strictly confidential. By completing this application you are verifying that you are able to live completely independently and do not need assistance of any kind. For couples, each individual will need to complete an application.

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Fields marked with an * are required.
Contact Information
Personal Information
E.g., 9/26/2023
Emergency Contacts
Emergency Contact 1
Emergency Contact 2
How did you hear about us?
Vacation Stay Dates Requested
First Choice
E.g., 9/26/2023
E.g., 9/26/2023
Second Choice
E.g., 9/26/2023
E.g., 9/26/2023
Third Choice
E.g., 9/26/2023
E.g., 9/26/2023
Goals & Activities During Your Stay
E.g., 9/26/2023
E.g., 02:39PM
Other Activities During Your Stay
Payment Method & Signature
At this time we are only able to accept payment by check or cash.
By completing the field below, you certify that the above information is true and that you are capable of living independently in a continuing care retirement community settting.