Application to The National Lutheran Home

Welcome to the application process.  First, please confirm that you have Adobe® Acrobat® Reader® software.  You will need Adobe® Acrobat® Reader® software to download and print the forms you and the doctor will need to complete.  If you don't already have the software you can download it for free by clicking on the logo below.  When you click on the Get Adobe Reader logo a new window will open with the instructions on how to download the software.  Once you have downloaded the software you can close that window and return to this one to complete the form below. 

If you already have Adobe® Acrobat® Reader® software then please proceed to the form below and complete the fields.   

Once you submit the form below you will automatically be taken to the next step of the application process, which will be to download and print out the Application for Admission and the Physical Exam Certificate.

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* Required fields

The following information should be answered by the person requesting the application:

Your First name: *    Your Last name: * 

Street address: * 

City: *    State: *    Zip: * 

Telephone including area code:  Home: *    Work: 

Email address: 

Your Relationship to prospective Resident/s: *  Self  Parent  Family Friend Other, please describe here: 

The following information should be answered about the prospective Resident/s:

Prospective Resident's name/s: 

First Name:  *   Last Name:  *

Age * (must be at least 65 years old)

How did you learn about the National Lutheran Home? * (please choose all that apply):  

Church  ~ Name of church:    

Family  Friend 

Advertisement (choose all that apply):  

              Guide to Retirement Living  Gazette  Senior Beacon  

              Website (please specify which website)   

              Search Engine (please specify which search engine) 

              Other: 

Are you interested in information regarding: * Independent Living Program Main Nursing Home Both

Comments: 

 Would you prefer that an application be mailed to you at the above address? * Yes  No

Please confirm the above information and if correct click Continue button below, if needed, click in the field above to edit or click Reset to start over.  Thank you.