Happy Day Adult Day Program Participant Inquiry Form

Welcome to Happy Day Support Adult Day Program!

Thank you for your interest in joining our community. We’re excited to help you explore our program and begin the enrollment process. Here’s what to expect:

Step 1: Complete this Inquiry Form
Filling out this form helps us understand your needs and interests.
Step 2: Schedule a Visit
Once we receive your form, we will reach out to arrange a convenient time for you to visit our center and see our program in action.
Step 3: Submit an Application
After your visit, if you decide our program is the right fit, you can complete an online application or fill one out while at our center.
Step 4: Alliance Health Coordination
After receiving your application, we will forward your information to Alliance Health for review and approval.
We will follow up with you in 2-3 business days and keep you updated on the next steps.

Thank you, and we look forward to welcoming you to Happy Day Support!

For any questions or additional information, please contact us at 919-862-7589 mvhappyday@icloud.com

Participant’s Name*

First NameLast Name

Age*

Medical Diagnosis *

Is the participant ambulatory?*

YesNo

Current Residence*

Private HomeGroup Home

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Payment Method*

Private PayMedicaid/Insurance

Transportation Needs:*

Is the participant an Alliance Health member?*

YesNo

Caregiver/Primary Contact Person:

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Does the participant have any special needs or require additional support?

Any other comments or information you would like to provide?

Thank you for your interest in the Happy Day Adult Day Program. We look forward to providing a supportive and enriching environment for your loved one. For any questions or additional information, please contact us at 919-862-7589 mvhappyday@icloud.com