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Applicant's Full Name:
Birth Date:
Sex:
Address:
Telephone:
Social Security #:
Medicaid #:
Medicare #:
SSI #:
Information about
Applicant:
Why are you interested in
coming to this program?
Have you had previous
experience in an Adult Day Care Program?
If yes, where and when?
Marital Status:
Present Living
Arrangements:
Living with whom:
Relationship:
Nearest Responsible
Relative:
Relationship:
If Employed, where:
Business Phone:
Home Address:
Home Phone #:
Emergency Care
Information:
Please list name of two
persons who may be contacted in case of emergency.
1.
2.
Name of Physician:
Address of Physician:
Physician's Phone #:
Date of Last Visit:
Name of Dentist:
Address of Dentist:
Dentist's
Phone #:
Date of Last Visit:
Services:
Transportation will be
provided by:
Arrival Time:
Departure Time:
Are you on a special diet?
If yes, give details below:
Food and/or drug allergies
that are known:
Days and times you will
attend center:
Contract and commitment:
I understand that the
participation in this program will be paid by:
Give name of person / party responsible that is mentioned
above:
Telephone number of
person to pay bill:
If emergency medical
care becomes necessary, I give permission for any
treatment the physician deems necessary. My hospital
choice is
,
but I may be treated at the nearest facility if the
emergency deems it necessary.
Please review
this form before submitting!
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