REGISTRATION FORM VCLA Adult Day Programs

VCLA Morning Activity Program (MAP) ~ SPRING 2025

REGISTRATION FORM
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:*

They can pay the full amount ($180 for 10 weeks).They can pay a partial amount ($50).They are requesting a full bursary (Pay What You Can).
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:*

MonthDayYear
Date
Referring agency if applicable:
Contact Name:*

First NameLast Name
Contact Phone Number 1:*
Please enter a valid phone number.
Contact Phone Number 2:
Please enter a valid phone number.
Contact Email Address:*
example@example.com
Would you like to add an emergency contact?*

Add emergency contactUse above contact for emergencies
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number 1:*
Please enter a valid phone number.
Emergency Contact Phone Number 2:
Please enter a valid phone number.
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?*

YesNo
Does the participant have any food allergies or dietary needs?*

YesNo
Please list all food allergies or dietary needs.*
Will the participant stay for the meal following the program?*

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

YesNo
Please list all disabilities.*
Does the participant use any adaptive technologies? E.g., wheelchair*

YesNo
Please list all adaptive technologies.*
Does the participant have any medical conditions we need to be aware of? E.g., diabetes*

YesNo
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?*

YesNo
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!
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VCLA Morning Activity Program (MAP) ~ SPRING 2025