Edgewood Retirement Center

200 West Edgewood Boulevard · Lansing, Michigan 48911 USA

Phone: 517-393-7777 · Fax: 517-393-6920
Email: WeCare@EdgewoodRetirementCenter.com

Please fill out all necessary information
to enable us to serve you more effectively.*

Applicant's name (first & last):

Name of person completing this form (if different than applicant):

Person completing form:
resident applicant care giver
family member

E-mail address:

Applicant's street address:

City & state

Zip code:

Applicant's Phone (incl. area code):

Phone # of person completing this form (if different than applicant):

What are you requesting?
(check all that apply)
information/brochure contact me
schedule a tour other (specify below)

When does the applicant desire to move in?

How did you hear about Edgewood?

Questions or Comments:

*We respect your privacy. Therefore, we will never sell, give, or otherwise
provide your name, address, telephone number, or other information to anyone.