Application for Enrollment

APPLICATION FOR ENROLLMENT

Enrichment Day Program
Thank you for your interest in Dementia Enrichment Center's Day Program! Our program provides supervised social, therapeutic, cognitive, and recreational services for people with mild to moderate dementia.

To attend the Enrichment Club Day Program, please complete the following steps.
- Ensure the person attending aligns with our Participant Profile.
- Submit the application for enrollment.
- If they haven't already met, schedule a meet-and-greet with the Director and the person with dementia. The meet-and-greet can take place at the Dementia Enrichment Center, or the Director is available to meet the participant in his/her home. During this visit, the Director will determine if the applicant presents as a candidate for the day program. (If the Director determines the applicant is not a fit for the program, the registration fee will be returned.)
- Discuss Participant's attendance schedule with the Director.
- The $80 registration fee will be added to your first invoice.
Please contact us if you have any questions or need assistance.

PARTICIPANT CRITERIA
Not all persons with Alzheimer's/dementia are suitable for our program. The following Participant Profile provides for specifics.

ENRICHMENT CLUB IS DESIGNED FOR PEOPLE WHO MAY HAVE THE FOLLOWING TRAITS

Participating in Activities
- Can do modified activities such as puzzles, games, art projects, and exercise
- Needs prompting to remember the purpose of activities
- Can get distracted during activities
- Needs activities broken down and presented one step at a time
- Benefits from verbal and/or visual step-by-step instructions
- May need help solving problems and navigating
Socializing with Others
- Initiates social contact and responds to the needs of others
- Seeks social interactions but may be more concerned with own needs
- May wait for others to initiate contact
- Can communicate own needs and desires
- May have trouble finding words or following conversations
Getting Around
- Walks independently (or using a mobility device)
- Gets in and out of chairs with occasional support
- Benefits from occasional support while walking or getting in/out of a chair
Mealtime & Toileting
- Needs assistance cutting foods into bite-sized pieces
- Feeds self independently
- Benefits from or relies on toileting reminders
- Can toilet and wash independently, sometimes with a little help to start
- Uses incontinence products appropriately
- May need help cleaning up after a toileting accident
OUR PROGRAM IS UNABLE TO ACCOMODATE PEOPLE WITH FOLLOWING NEEDS AND BEHAVIORS

Participating in Activities
- Needs 1:1 attention to engage in group activities
- Has limited comprehension
- Is unable or refuses to engage in the majority of activities
Socializing with Others
- Is frequently suspicious of others
- Displays aggressive, combative, inappropriate, or unsafe behavior
- Does not honor personal space of others (i.e. takes food/objects, touches or pets, tightly hugs or shakes hands)
Getting Around
- Relies on frequent support walking or getting in/out of a chair
- Refuses or is unable to use necessary mobility device
Mealtime & Toileting
- Requires foods to be blended or mashed
- Relies on others to be fed
- Relies on 1:1 toileting or incontinence assistance
Behavior
- Is frequently or easily upset, angered, anxious, or depressed
- Experiences upsetting hallucinations
- Attempts to exit secure areas (i.e., climb fences, force open locked doors, flee)
I have read and understand the criteria for admission to the Enrichment Day Program and verify the applicant meets these criteria.
Responsible Party's signature*

Clear
Date*

MonthDayYear
Date

How did you hear about the Dementia Enrichment Center*
PARTICIPANT
Participant Name*

First NameLast Name
Preferred Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Birth Date*

MonthDayYear
Date
Age*
Gender*

PRIMARY CONTACT
Name*

First NameLast Name
Relationship*
Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
Invoices will be sent to this email address, unless otherwise notified

SECONDARY CONTACTS
Emergency Contact 1*
Phone*
Emergency Contact 2*
Phone*

MEDICAL INFORMATION
YesNo
If yes, when?
Allergies*
Dietary needs/limitations*
Significant physical or mental health conditions/history*

SOCIAL HISTORY
Alonew/Spousew/Siblingw/Child(ren)Other
SingleMarried/PartneredSeparated/DivorcedWidowed
Name(s) and relationship(s) of important people in Participant's life/past*
(parents, siblings, spouse(s), children, etc.)
Names of important places in Participant's life/past*
(hometown, college/university, long-time place of employment, etc.)
Armed Forces service
(branch, rank, years of service, medals, duty stations)
Meaningful groups, clubs, memberships in Participant's life/past *
(religious/church, civic organizations, teams, scouting, Greek life, professional organizations)
Memorable events, accomplishments, activities*
Hobbies or interests*
Favorite musicians/bands or genres of music*
Specific dislikes or fears*
Topics/things that may be upsetting*
Other information to share about Participant:

TERMS OF PARTICIPATION
I have read and understand the Dementia Enrichment Center’s TERMS OF PARTICIPATION and agree to abide by the conditions set forth herein.
Responsible Party Signature*

Clear
Date*

MonthDayYear
Date

RELEASE OF LIABILITY
- Responsible Party understands Enichment Club takes place in a secure environment and Participants are unable to leave at their own will.
- Responsible Party hereby acknowledges and agrees that he/she will be held responsible and liable for any damage to Dementia Enrichment Center, Dementia Enrichment Center's property, or the property of other Participants of Dementia Enrichment Center, if such damage is due to behavior or actions or inactions of Participant or Responsible Party. Participant, Responsible Party, and their heirs and assigns, shall indemnify and hold Dementia Enrichment Center harmless from any and all claims, suits, and actions asserted against Dementia Enrichment Center relating to damage or injury to property or a person, including Dementia Enrichment Center, caused by Participant or Responsible Party. Responsible Party understands that Dementia Enrichment Center is liable for injuries to Participant or Participant's property only insofar as those injuries are caused by negligent or intentional wrongful acts or omissions of Dementia Enrichment Center and recoverable by law.
- Due to the cognitive impairment of the Participants, Dementia Enrichment Center cannot be held responsible for any damage or loss to Participant items of any monetary or sentimental value. Dementia Enrichment Center is not responsible for any valuables or money left in the care of the Participant and will not replace lost items or money.
- Dementia Enrichment Center shall not be liable or responsible for the loss or destruction of any personal property belonging to Participant or Responsible Party due to theft or any cause beyond the immediate control of Dementia Enrichment Center. Participant and Responsible Party shall bear responsibility over their personal property brought to Dementia Enrichment Center.
- Responsible Party understands and agrees that Dementia Enrichment Center is liable for injuries only insofar as they are caused by negligent or intentional wrongful acts or omissions of Dementia Enrichment Center and recoverable by law. Participant, Responsible Party, and their heirs and assigns shall indemnify and hold Dementia Enrichment Center harmless from any and all claims, suits, and actions brought against Dementia Enrichment Center relating to damage or injury to property or a person, including Dementia Enrichment Center, caused by Participant or Responsible Party.
I have read and understand the Dementia Enrichment Center's RELEASE OF LIABILITY.
Responsible Party Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

APPLICATION FOR ENROLLMENT

PARTICIPANT CRITERIA

I have read and understand the criteria for admission to the Enrichment Day Program and verify the applicant meets these criteria.

PARTICIPANT

PRIMARY CONTACT

SECONDARY CONTACTS

MEDICAL INFORMATION

SOCIAL HISTORY

FUNCTIONAL SNAPSHOT

TERMS OF PARTICIPATION

I have read and understand the Dementia Enrichment Center’s TERMS OF PARTICIPATION and agree to abide by the conditions set forth herein.

RELEASE OF LIABILITY

I have read and understand the Dementia Enrichment Center's RELEASE OF LIABILITY.