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Assisted Living Residences Forms

Assisted Living Registry Notice of Changes to Registrar

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Assisted Living Registry Notice of Changes to Registrar

This form is to be used for updating the contact information on an existing registered Assisted Living residence as per ALR regulation.

The Assisted Living Regulation requires that a Registrant (Operator) must provide to the Registrar notification of changes to a registration. Notification of changes, and approval, if applicable, are specified in sections 9 and 10 of the Assisted Living Regulation.

See Notice to Registrar of Changes Factsheet for additional information.

Premises Information

Residence NameMissing or incorrect value

Applicant / Operator Legal NameMissing or incorrect value

Residence AddressMissing or incorrect value

CityMissing or incorrect value

Province

Postal codeMissing or incorrect valueFormat as A1A 1A1

Phone Number 555-555-5555 Missing or incorrect value

Fax Number 555-555-5555

Residence EmailMissing or incorrect value

mailing address is different than above

Registrant Information

Registrant Legal NameMissing or incorrect valuee.g., corporation, society or individual’s name

Contact NameMissing or incorrect value

Contact Position TitleMissing or incorrect value

Contact Phone number 555-555-5555 Missing or incorrect value

Contact Email addressMissing or incorrect value

Indicate the type of change(s) and provide details of the change

Registrant/Operator contact information

Name of the residence

Address of residence (moving locations)

Ownership

Residence contact information (phone or email)

Manager

Numbers of units

Number of residents

Structure or floor plan changes/renovations

Class of assisted living

Closure of residence

Residence Location (moving)

Add, change, remove Assisted Living Services

Support with activities of daily living

Assistance with managing medication

Therapeutic diets support

Safekeeping of money and other personal property

Behaviour management support

Programming (or psychosocial) supports

Signature

By checking this box I affirm that the information I have provided is correct.

Name (First, Last)Missing or incorrect value

Date

If you want to keep a copy for your records, you can download a copy using the PDF button below.

Should you have any questions, please contact:

Assisted Living Registry

Ministry of Health

PO Box 9601, Stn Prov Govt

Victoria, BC V8W 9P1

Email: hlth.assistedlivingregistry@gov.bc.ca

Phone: 1-866-714-3378

Fax: 250-953-0496

HLTH 8117 Rev. 2023/09/26

613d1d9e4af39dd11ae2000a3a796162433cb18b

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