Adult Day Program Interest Form

City of Peoria

Adaptive Programs

Adult Day Program Interest Form
Section 1: Participant Information
1. Full Name of Participant *

First NameLast Name
2. Date of Birth*

MonthDayYear
Date
MaleFemalePrefer not to sayOther
EnglishSpanishOther
Lives aloneWith familyGroup homeDevelopmental homeOther
6. Primary Diagnosis/ Reason for Program Interest if comfortable sharing
Section 2: Caregiver/Primary Contact Information
1. Caregiver/Primary Contact Full Name*

First NameLast Name
SpouseChildSiblingFriendLegal GuardianOther
3. Mobile Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home/Other Number
Please enter a valid phone number.Format: (000) 000-0000.
4 Email Address*
example@example.com
5. Mailing Address*
City*
State*
Zip*
Section 3: Program Needs and Preferences
ASAPWithin 1 month1-3 monthsFlexible
Full Time (4-5 days a week)Part Time (2-3 days a week)
MondayTuesdayWednesdayThursdayFriday
Will provide own transportationParatransit, Valley MetroDial-A-RideUnsure
Social ActivitiesCognitive stimulationPhysical activities/ExerciseOther
Section 4: Additional Information
Is there anything else you would like us to know*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: