Adult Day Program (ADP) Registration Form

Enrollee Information

Enrollee Name

First

Last

Date of Birth (dropdown)//

Gender (dropdown)

Address

Address Line 1

City

State

Zip Code

Email

Phone

Last 4 Digits of Enrollee's SS#

Living Arrangements (dropdown)

What transportation will be used to and from the Learning Center?

Responsible Party Information

Responsible Party Name

First

Last

Relationship to Enrollee (dropdown)

Address

Address Line 1

City

State

Zip Code

Email

Phone

Emergency Contacts

Emergency Contact #1 Name

Phone

Relationship

Emergency Contact #2 Name

Phone

Relationship

Medical Information

Enrollee's Medical Diagnosis

Physician's Name

Physician's Phone

List Known Allergies and/or Medical Conditions:

Medication #1

Dosage

Frequency

Medication #2

Dosage

Frequency

Medication #3

Dosage

Frequency

List All Other Medications, Doses, and Frequencies

Cognitive/Behavioral History

Is the Enrollee Oriented to Work with People?

Yes
No

Is the Enrollee Oriented to Place?

Yes
No

Is the Enrollee Oriented to Time?

Yes
No

Does the Enrollee Understand Verbal Directions?

Yes
No

Does the Enrollee Understand Written Directions?

Yes
No

Does the Enrollee Communicate Needs (thirst, bathroom, hunger, etc.)?

Yes
No

Is the Enrollee Aware of Danger, Risks, and Consequences?

Yes
No

Is the Enrollee Receiving Mental Health Treatment?

Yes
No

Nutrition Information

Does the Enrollee Have a Special Diet

No
Yes

If Yes, please explain in the fields below.

Does the Enrollee Have a Good Appetite

Good
Fair
Poor

Please List Food Allergies

Please List Troublesome Foods

Please List Special Instructions for Meals

Medical Release & Consent Agreement

Today's Date (dropdown)

Digital Signature for Medical Release & Consent *

In case of emergency, I understand that every effort will be made to contact the responsible party. If I cannot be reached, I hereby give permission to Jasmine Nyree Campus to contact appropriate emergency medical assistance. A Jasmine Nyree Campus staff member will remain until the responsible party, or another authorized adult arrives. Jasmine Nyree staff may not transport program participants.