Adult Day Program (ADP) Registration Form Held from 7:30 am to 2:30 pm, Monday to Friday Please enable JavaScript in your browser to complete this form. - Step 1 of 7Enrollee InformationEnrollee NameFirstLastDate of Birth (dropdown)MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender (dropdown)FemaleFemaleMaleAddressAddress Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmailPhoneLast 4 Digits of Enrollee's SS#Living Arrangements (dropdown)Enrollee Lives with SomeoneEnrollee Lives with SomeoneEnrollee Lives AloneOtherWhat transportation will be used to and from the Learning Center? NextResponsible Party InformationResponsible Party NameFirstLastRelationship to Enrollee (dropdown)Legal GuardianLegal GuardianPower of AttorneyAddressAddress Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmailPhoneNextEmergency ContactsEmergency Contact #1 NamePhoneRelationshipEmergency Contact #2 NamePhoneRelationshipNextMedical InformationEnrollee's Medical DiagnosisPhysician's NamePhysician's PhoneList Known Allergies and/or Medical Conditions:Medication #1DosageFrequencyMedication #2DosageFrequencyMedication #3DosageFrequencyList All Other Medications, Doses, and FrequenciesMedical Devices Used (Select All Applicable)WalkerCaneWheelchairProstheticHearing AidGlassesCatheterFeeding TubeOtherOxygenNextCognitive/Behavioral HistoryActivities of Interest (Select All Applicable)Arts & CraftsTable GamesPhysical GamesSocializingBooks & MagazinesExerciseSensory ActivitiesOtherIs the Enrollee Oriented to Work with People?YesNoIs the Enrollee Oriented to Place?YesNoIs the Enrollee Oriented to Time?YesNoDoes the Enrollee Understand Verbal Directions? YesNoDoes the Enrollee Understand Written Directions?YesNoDoes the Enrollee Communicate Needs (thirst, bathroom, hunger, etc.)? YesNoIs the Enrollee Aware of Danger, Risks, and Consequences?YesNoIs the Enrollee Receiving Mental Health Treatment?YesNoNextNutrition InformationDoes the Enrollee Have a Special DietNoYesIf Yes, please explain in the fields below.Does the Enrollee Have a Good AppetiteGoodFairPoorPlease List Food AllergiesPlease List Troublesome FoodsPlease List Special Instructions for MealsNextMedical Release & Consent AgreementToday'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.Submit