Encore Care - Day Campus

Encore Care - Day Campus

Adult Day Support Services
Start Date

MonthDayYear
Date
Name of Client*

First NameLast NameNick Name
Please take a photo so we may share with the team during their training about you.
Date of Birth

MonthDayYear
Date
Do you permit us to celebrate or give recognition of your birthday with co-attendees?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person

PrefixFirst NameLast Name
Relationship to Client
Are you the client's guardian, authorized representative, or advocate
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Is it ok to text this number?*
Allergies*
Care Needs*
Interests*
Goals*

Communication*

	Independent	Assistance	Dependent
Communication
Understanding verbal instructions
Emotional identification & self awareness
Maintain own privacy and dignity
Maintain own safety

Comments

Nutrition*

	Able	Assisted	Unable
Meals & snacks
Fluid intake
Medication

Special Instructions or Comments

Mobility*

	Independent	Assistance	Dependent
Bed mobility
Transferring
Mobilising
Toileting
Personal hygiene

Please share additional interesting facts about yourself you would like us to know
What days are you enrolling to attend*

MondayTuesdayWednesdayThursdayFriday

Individuals that report they aren't feeling well and have a temperature between 99.5 F and 100. 3 will be asked to be picked up from the facility or brought home early.*

I understand
Is the client permitted by the guardian to access their social media account while in attendance at Encore Care -Day Campus?*

YesNo
Is the client permitted by the guardian or representwtive to access and search the internet while in attendance at Encore Care- Day Campus?*

YesNo
Please be advised that all client's that are permitted to use social media and the internet will have the opportunity to attend Encore's internet saftey session while at the facility. This session informs them of keeping their information confidential, danger of sexting, being catfished, etc.*

Yes I want to attendNo I do not want to attend
I do hereby grant and give Encore Care Association Ltd. the right to use my or my child’s photograph or image with or without my or my child's name, or the name of the person I am authorized to resresent, both single and I conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising, publicity and promotion relating thereto without any compensation for use. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold Encore Care Association Ltd. harmless of and from any and all liability of whatever nature which may arise out of result from such fees. For the consideration stated above, I further agree that in the event my child or the person I am authorized to represent on this form repudiates or attempts to repudiate such release, I will personally indemnify and save harmless Encore Care Association Ltd., its successors and assigns, for any and all loss and damage occasioned thereby:*

Yes I authorizeNo I opt. out
Authorization WAIVER FOR PARTICIPANT AND BY PARENT/GUARDIAN:

In consideration of your accepting me, my child’s, or the person I am authorized on this form to represent entry. I hereby, for myself, my child, my heirs, executors and administrators, waiver and release any and all rights and claims for damages I, my child, or the person I am authorized to represent on this form may have against the Encore Care Association Ltd. and its representatives, successors and assigns for any and all injuries suffered by myself,my child, or the person I am authorized to represent on any activity sponsored by these groups.
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