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1
Current program hours with grant funding (for qualified recipients): FULLY FUNDED HOURS STARTING JULY 9, 2021:
*
This field is required.
FUNDED HOURS will be Monday through Sunday, 5 am to 11 pm.
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2
ID Number
*
This field is required.
Please enter the birthday of the ADS participant that attends our program (format: MMDDYY, so January 3, 1942 would be entered like this: 010342
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3
ADS Participant Name:
*
This field is required.
This field should auto-fill. If it doesn't, please notify the front office, or email Nancy at Nancyb@woodhavenrc.org, please fill in the participant name and click "next".
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4
Contact info
*
This field is required.
If this is not the best emergency contact for today, please edit accordingly (we need name + valid phone number).
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5
Email
If you provide us a valid email, we will add it to our system and send you a copy of your loved one's sign and sign out information (you won't have to enter it every time).
example@example.com
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6
Action:
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This field is required.
Sign in
Sign out
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7
Estimated pick up time:
Please give us your best guess for when you will be picking up your loved one today.
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Hour
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Minutes
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8
Neighborhood:
*
This field is required.
Please select the area where your loved one spends his/her day.
Traditional
Secured (Memory Care Center)
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9
Would you like your loved one to receive dinner tonight?
Please note that dinner is served at 5 pm, for pickups at 4:30 p or 5 p, we want to know if you want us to serve your loved one dinner if you happen to be late for some reason.
Yes
No
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10
Time Correction
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11
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