ADC Application

Blue Ridge Community Action, Inc. Adult Day Services Application for Enrollment
Applicant’s Full Name
DOB
Sex
Street Address
City, State, Zip
Telephone Number
Please enter a valid phone number.
Social Security Number
Why are you interested in coming to this program?
What physical/mental challenges are you facing?
Have you had previous experience in a day program?

YesNo
If yes, where and when?
Marital Status

MarriedSingleSeparatedWidowedDivorced
Present living arrangements

With relativesWith non-relativesAlone in house/apartmentAlone in single room
Living with whom?
Relationship with person you live with?
Nearest responsible relative
Relationship to nearest responsible relative
If employed, where?
Work phone?
Home Address
Home phone
Please list the names of two persons who may be contacted in case of emergency (contact persons must have telephone):
Name of first emergency contact
Relationship to first emergency contact
Street address for first emergency contact
City, State, Zip for first emergency contact
Phone number for first emergency contact
Name of second emergency contact
Relationship to 2nd emergency contact
Street address for second emergency contact
City, State, Zip for second emergency contact
Phone number for second emergency contact
Name of Physician who will see you on request
Phone number for Physician who will see you on request
Name of Dentist who will see you on request
Phone number for Dentist who will see you on request
Transportation provided by:

Relative/FriendPublic Transportation
Relative/Friend (Specify Name)
Arrival Time
Departure Time
Do you have special dietary needs?
Days of attendance
Part-time (list days)
Part-time (list days)
The day service program policies have been explained to me and I have been given a copy of the program policy. I understand that participation in this program will be paid for by:

Department of Social ServicesMyselfRelativeOther
Other (specify)
Rate
Rate
Applicant Signature
Date

MonthDayYear
Date
ADVANCE DIRECTIVE NOTIFICATION
Family member does not require a POA, may make his/her own medical or other decisions, and may sign for his/her self legally.

Family member has a Power of Attorney or legal guardian
Type a question

Family member does not require a POA, may make his/her own medical or other decisions and may sign for his/her self legally.Family member has a Power of Attorney or legal guardianFamily member has an advance directive; Living Will, Health Care Power of Attorney, DNRI will provide the day program with an original copy of the DNR order, and copies of other advance directives.Family does not have an advance directive.
Name of POA/guardian if applicable
Phone # of POA/ guardian if applicable
If family does not have an advance directive check an option below:

I would like information on how to obtain an advance directiveFamily member does not want an advance directive
Applicant Signature

Clear
Date

MonthDayYear
Date
Responsible Party Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

ADVANCE DIRECTIVE NOTIFICATION