The Day D.E.N Program Application

The Day D.E.N Program Application
Day D.E.N. Rules Document
Please review the Day D.E.N. rules before completing your application:
🔗 Click here to view the Day D.E.N. Rules
Upload Your Supporting Documents Here

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Applicant Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Applicant E-Mail
Emergency Contact Name
Relationship
Phone Number

Area CodePhone Number
Emergency Contact Email
example@example.com
Legal Representative

Other
How did you hear about ROAR Florida?
Support Services Disclaimer for Day D.E.N. Participants

ROAR Florida does not provide individualized support services for participants in the Day D.E.N. program. It is the responsibility of applicants, their legal representatives, and/or family members to ensure that any necessary supports are in place before participation. We recognize that some individuals may require assistance in specific areas in order to fully and safely engage in our programming. Therefore, as part of the application process, confirmation must be provided by the applicant and/or their legal representative that adequate support is already in place for program participation.
Current Support Services
Legal Representative or Primary Contact Information
Legal Representative Name

First NameLast Name
Legal Representative Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Representative Email
example@example.com
Legal Representative Phone Number

Area CodePhone Number
Legal Representative Phone Number

Area CodePhone Number
Primary Contact Name

First NameLast Name
Primary Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Phone Number

Area CodePhone Number
Primary Contact Email
example@example.com
What are the most important things we should know about the applicant in an emergency?
Primary Contact Phone Number

Area CodePhone Number
Medical and Emergency Information
Does the applicant require an EpiPen or another emergency treatment for an allergic reaction?
Is the applicant able to administer an EpiPen independently?
If yes, please list the applicant’s allergies.
Does the applicant have a history of seizures?
When was the applicant’s last seizure?

MonthDayYear
Date
If yes, what type?
How long do the applicant’s seizures typically last?
Minutes
How often does the applicant experience seizures?
Describe how the seizures are managed:
Examples: VNS, rescue medication, or daily medication
Can the applicant self-administer seizure medication without assistance?
Does the applicant use any adaptive equipment?
If yes, please check all that apply:

Other
Does the applicant use splints?
If yes, what type?
Does the applicant use a communication device?
If yes, what type?
Dietary and Mealtime Needs
Does the applicant require any special dietary requirements?
If yes, describe:
Are there any mealtime safety concerns for the applicant, such as choking, aspiration, or stuffing food into their mouth?
If yes, please describe:
Participation and Support Needs
Date/Time
Can the applicant safely participate in group activities without one-to-one support?
Does the applicant require assistance with any of the following during Day D.E.N.?
If assistance is required, who will attend with the applicant and provide the required assistance?
Can the applicant independently manage and take any medication needed during Day D.E.N.?
Can the applicant follow basic safety instructions and remain with the group?
Please explain what assistance the applicant requires.
Please describe any accommodations, communication methods, triggers, or strategies that help the applicant participate successfully.
Can the applicant independently manage their restroom and personal-care needs while attending Day D.E.N.?
Can the applicant eat and drink independently without staff assistance?
Does the applicant need a support person to accompany them during Day D.E.N.?
ROAR FLORIDA does not provide individualized assistance with toileting, personal care, feeding, medication administration, or one-on-one supervision. If assistance is needed in these areas, an appropriate support person must accompany the participant.
Please describe why you would like to participate in ROAR Day D.E.N:
Who will attend with the applicant and provide the required assistance?
If assistance is required, who will attend and provide that support?
Can the participant remain with the group during activities?
Consent to Disclose Personal and Health Information & Applicant Acknowledgment

I, the undersigned applicant or legal representative, give ROAR Florida permission to collect, store, and disclose relevant personal and health information provided as part of the application and participation in the Day D.E.N. program. This includes, but is not limited to, medical history, diagnoses, medications, emergency contacts, and any other information necessary to support safety and informed program participation. I understand that this information will be kept confidential and stored in accordance with all applicable regulatory requirements and/or best practices. Information will only be shared with staff or professionals on a need-to-know basis to support the safety and well-being of the applicant. I understand that completion of this application does not guarantee acceptance into any of ROAR Florida's Day D.E.N. programs. I affirm that all information provided in this application is true and accurate to the best of my knowledge and that no relevant information has been knowingly omitted.
Signature of applicant
Signature of person assisting with this application
Signature
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The Day D.E.N Program Application

Support Services Disclaimer for Day D.E.N. Participants

Legal Representative or Primary Contact Information

Medical and Emergency Information

Dietary and Mealtime Needs

Participation and Support Needs

Consent to Disclose Personal and Health Information & Applicant Acknowledgment