Register

Applicant's Full Name:

Applicant's Birth Date:

Applicant's Gender:
MaleFemale

Full Address:

Medicaid #:

Medicare #:

Supplemental Security Income #:

Information about the Applicant:

Tell us why you are interested in joining this program?

Have you had previous experience in an Adult Day Care Program?
YesNo
If yes, where and when?

Marital Status:
---MarriedSingleSeparatedWidowedDivorced

Present Living Arrangements:
---with relativeswith non-relativesalone (house or apartment)along (single room)

Living with whom:

Relationship with whom their living:

Nearest Responsible Relative:

Relationship to nearest relative:

If employed, where:

Business phone:

Emergency Care Information:

Please list name of two persons who may be contacted in case of emergency.

Emergency Contact #1

Emergency Contact #2

Physician Information

Dentist Information

Services:

Transportation will be provided by:
---relative or friendpublic transportationBlessed Assurance

Arrive Time

Departure Time

Special diet?
YesNo

If yes, give details below:

List all food and/or drug allergies:

Days and times requested to be at Blessed Assurance:

Contract and Commitment:

I acknowledge that the participation in this program will be paid by:
---myselfrelative (give name below)another party (give name below)

Give name of person/party responsible that is mentioned above:

Phone Number of person to pay bill:

Your Email

If emergency medical care becomes necessary, I give permission for any treatment the physician deems necessary. My hospital choice is , but I (the applicant) may be treated at the nearest facility if the emergency deems it necessary.

By entering your full name below you are digitally signing this form. Please enter your full name:

Please review this form before submitting!