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Enrollment Application
Applicant's Full Name

First NameLast Name
Applicant's Birth Date

MonthDayYear
Date
Applicant's Gender
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medicaid Number
Medicare Number
Supplemental Security Income Number
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?
If yes, where and when?
Marital Status
Present Living Arrangements
Living with whom
Relationship with whom their living
Nearest responsible relative
Relationship to nearest relative
If employed, where
Business phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Care Information

Please list name of two persons who may be contacted in case of emergency
Emergency Contact #1
Full Name

First NameLast Name
Relationship to applicant
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2
Full Name

First NameLast Name
Relationship to applicant
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Information
Physician Name

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of last physician visit

MonthDayYear
Date
Dentist Information
Dentist Name

First NameLast Name
Dentist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of last dentist visit

MonthDayYear
Date
Services
Transportation will be provided by
Arrive time
Departure time
Special diet?
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
Give name of person/party responsible that is mentioned above
Phone Number of person to pay bill
Please enter a valid phone number.Format: (000) 000-0000.
Your email
example@example.com
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.
Your Signature
Today's Date

MonthDayYear
Date
Please review this form before submitting!
Should be Empty:

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Information about the applicant

Emergency Care Information

Services

Contract and Commitment