Caregiver Bridge Participant Application
Participant's Full Name:
*
Participant's Preferred Name:
*
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
-
Month
-
Day
Year
Date
Primary Caregiver:
*
Primary Cell Phone:
*
Format: (000) 000-0000.
Caregiver Email Address
example@example.com
Secondary Contact Person
Secondary Number:
Format: (000) 000-0000.
How did you hear about Caregiver Bridge?
Consent:
As the family member/caregiver for the participant named above, I give my permission for her/him to participate in Coffee Club; the Adult Social Day Program for those experiencing memory impairment at Caregiver Bridge (from here out called CB).
I give my permission for CB to use our names or photographs to promote the program of respite care.
I give permission for the above participant to go on any field trips or walks deemed appropriate by the volunteers at CB.
I will not hold CB liable in case of accident or injury.
I give CB permission to copy the participants COVID vaccine card.
I understand that during the transition period needed by the above participant into the Coffee Club program that I must be within 15 minutes of the center in case my participant needs support.
Conditions for Service:
At no time is a CB member or volunteer authorized to assist with or manage medication; should the participant require medication(s) be taken during their visit, (1) participant must be independently capable to manage the intake of their medication or (2) a caregiver must present the medication in person to the participant.
Participant must be able to self-toilet; includingn undressing one's self, elminiating, and cleaning up before dressing and leaving the restroom. Volunteers are available to assist with guidance to and from the restroom, as well as reminders to use the restroom throughout their visit.
Please read and select one:
*
I am financially able to pay the fee requested for participating in the program.
I am unable to pay the fee for participation in the program and am requesting a scholarship.
Please read and select one:
*
I give my permission for CB to use our first name, photos or videos to promote the program.
I do not give my permission for CB to use our first name, photos or videos to promote the program.
Signed:
Signature
*
Relationship to participant
Spouse / Child / Roommate
EMERGENCY CONTACTS
Next of Kin:
*
Relationship:
*
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
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Home Address:
*
General Heath
Diagnoses
Self-Care Capabilities
Considerations or Restrictions
*
Requires support with transfers to and from chair
Wonders, will need redirecting
Gets anxious / restless
Experiences hallucinations
Needs reminders to go to the bathroom
Needs to go on a walk with a volunteer
Needs to rest, often
Uses a wheelchair
Uses a cane / walker
Dysphagia (difficulty or discomfort in swallowing)
Other
Is participant registered with the Alzheimer's Association "Safe Return" program?
*
Yes
No, I'd like help with this
Not needed, participant is not at risk of wandering
Toilet considerations
*
Independent
Needs reminders
Uses incontinence products
Needs support getting to the restroom
Diet Considerations (e.g. help with eating, special foods or allergies?)
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Frustrations and Behavior Patterns: What are the cues or triggers that may lead to frustration, anxiety, stress?
Close Family Members and Friends
Occupation History
Current Household Members Including Pets
Hobbies & Special Interests
Favorites (colors, flowers, music, movies, places, etc)
Special Needs: Please give any specific "helpful hints" or accommodations needed
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