JRC Adult Day Center Enrollment Application

JRC Adult Day Center Enrollment Application
Member Name:
Last
First
Middle
Member Address:
Number
Street
City
State
Zip
Member Phone Number:
Email
example@example.com
Phone Number
000-000-0000
Emergency Contact #1 Information
Emergency Contact Information (Please list 2)-Could be: Child/Next of Kin/Guardian
Name

First NameLast Name
Relationship
Email
example@example.com
Number
Emergency Contact #1 Address
Street
City
State
Zip
Emergency Contact #1 Phone Numbers
Home Number
000-000-0000
Cell Number
000-000-0000
Emergency Contact #2 Information
Name

First NameLast Name
Relationship
Email
example@example.com
Emergency Contact #2 Address
Number
Street
City
State
Zip
Emergency Contact #2 Phone Numbers
Home Number
000-000-0000
Cell Number
000-000-0000
Referral Information
Referral Received from:

SelfFamilyPhysicianConcerned PartyCommunity Agency
Name of Referral
Average Monthly Income ($)
Source of Income
(Social Security / Pension / Family)
Days of attendance preferred:

MondayTuesdayWednesdayThursdayFriday
Transportation required:

None NeededBoth Needed1 Way to Center1 Way Back Home
Social Security
Date of Birth

MonthDayYear
Date
Medicare #
Medicaid #
Check the following categories that apply to Applicant

Lives AloneNeeds respite for family or caregiverNeeds supervision of nutrition or other ADL’s (Activity of Daily Living)Has been referred by physician and or social workerLack of support systemLives with disabled personUses walker, crutches, cane, or wheelchairLegally blindDeafAmputation of limbsOther physical or cognitive impairment that would prevent client from performing ADL’s (Activity of Daily Living)Over 60 years of age
Signature of Member

Clear
Date

MonthDayYear
Date
If client is unable to sign, relative or guardian must sign.
Signature

Clear
Relationship
Date

MonthDayYear
Date
Should be Empty:

JRC Adult Day Center Enrollment Application

Member Name:

Member Address:

Member Phone Number:

Emergency Contact #1 Information

Emergency Contact #1 Address

Emergency Contact #1 Phone Numbers

Emergency Contact #2 Information

Emergency Contact #2 Address

Emergency Contact #2 Phone Numbers

Referral Information