Ready to Join KSLA? It's easy! Just complete the web form below. Application - Provider Member Community Name* Contact Person's Name & Title* First Last Title E-Mail Address* Office Phone Number*Cell Phone NumberFax NumberCommunity Website* Please Upload Your Company Logo Here*Accepted file types: jpg, png, Max. file size: 100 MB.Community Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County In Which Community is Located* Is This the Mailing Address?* Yes No Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner's Name* First Last Owner's Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner's Office Phone Number*Owner's Cell Phone NumberOwner's Fax NumberOwner's E-Mail Address* Is Your Community Currently Under Construction or Not Yet Open?* Yes No What is Your Anticipated Opening Date? MM slash DD slash YYYY Upon Completion, How Many ALC (Social Model) Licensed Apartments will Your Community Have? Upon Completion, How Many ALC-BH Licensed Apartments will Your Community Have? Upon Completion, How Many ALC-DC Licensed Apartments will Your Community Have? Upon Completion, How Many Independent Living Apartments will Your Community Have? Annual Dues - Under Construction Price: KSLA Annual Dues Investment for Assisted Living Community Living Units, Personal Care Home Beds, or Independent Living Apartments that are currently under construction or not yet in operation. This amount will be applied to your Dues Investment once in operation. Does Your Community Have Licensed ALC Apartments?* Yes No How Many Social Model ALC-Licensed Apartments are there in your Community?How Many ALC-BH Licensed Apartments are there in your Community?How Many ALC-DC Licensed Apartments are there in your Community?Annual Assisted Living Dues Investment for Communities with 1-12 Living UnitsIf there are 12 Living Units or fewer, the minimum dues are $300 per year. Price: Annual Dues Investment for Assisted Living Communities with 13-99 Living UnitsDues for communities with 13-99 Living Units are $25 per Living Unit per year. Price: $25.00 Quantity: Annual Assisted Living Dues Investment for Communities with 100+ Living UnitsIf there are 100 Living Units or more, the maximum dues are $2,500 per year. Price: Does Your Community Have Independent Living Living Apartments?* Yes No How Many Independent Living Apartments are there in your Community?Annual Dues Investment for Communities with 1-50 Independent Living ApartmentsAnnual Dues for Independent Living Apartments are $12 per Independent Living Apartment, up to 50 Independent Living Apartments. Price: $12.00 Quantity: Annual Dues Investment for Communities with 51+ Independent Living Apartments Price: The Annual Dues Investment for Independent Living Apartments is $600 per year for communities with over 50 Independent Living Apartments.Total Dues Investment $0.00
KSLA@KentuckySeniorLiving.org PO Box 232, LaGrange, KY 40031 Phone: 502.938.5102 Thank You to our 2023 Platinum Sponsor, GerwickPurchasing!
