REGISTRATION FORM VCLA Adult Day Programs

This spring, Valley Community Learning Association is offering our Morning Activity Program only on Tuesdays, 10:00 am to 12:00 pm, followed by lunch until 12:30 pm. MAP Spring 2025 will run from April 8 to June 10.

Participant Name:

First NameLast Name

We offer our Adult Day Programs on a sliding fee scale to enable broad participation. We are committed to enabling access regardless of economic means.

Please tell us if the participant needs a bursary:

Payments are payable by

(a) cheque to Valley Community Learning Association,

(b) cash, OR

(c) e-transfer to VCLA Financial Administrator Sandi Dennis (sandi.vcla@gmail.com; security question answer: map).

Birthday:

Date

Referring agency if applicable:

Contact Name:

First NameLast Name

Contact Phone Number 1:

Please enter a valid phone number.Format: (000) 000-0000.

Contact Phone Number 2:

Please enter a valid phone number.Format: (000) 000-0000.

Contact Email Address:

example@example.com

Would you like to add an emergency contact?

Emergency Contact Name:

First NameLast Name

Emergency Contact Phone Number 1:

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Phone Number 2:

Please enter a valid phone number.Format: (000) 000-0000.

Participants with developmental disabilities or dementia, etc need to come with a caregiver or support worker. Caregivers/Support-workers attend free-of-charge.

Will the participant be attending with a caregiver or a support worker?

Does the participant have any food allergies or dietary needs?

Please list all food allergies or dietary needs.

Will the participant stay for the meal following the program?

Does the participant have disabilities? E.g., physical limitations,speech/hearing limitations

Please list all disabilities.

Does the participant use any adaptive technologies? E.g., wheelchair

Please list all adaptive technologies.

Does the participant have any medical conditions we need to be aware of? E.g., diabetes

Please list all medical conditions we need to be aware of.

Does the participant have any behaviour risks or triggers we need to be aware of?

Please list all behaviour risks or triggers we need to be aware of.

What is the participant interested in doing or learning?

If there is anything else you would like us to know, please write it here.

Thank you!

We will be in touch soon once you submit this form!

VCLA Morning Activity Program (MAP) ~ SPRING 2025