Enfield Adult Center Application

1A Beech Road, Enfield, CT 06982

Phone: (860) 763-7538   Fax: (860) 763-7584

E-Mail: Adult Day Care

 

Family and Personal Information

Full Name :
Address :
Telephone Number :
Date of Birth : (dd/mm/yy)
Place of Birth :
Marital Status : Married   Single   Divorced   Widowed  

 

Name of husband or wife, if living :
With whom does applicant live? :

 

Your Children Address

Telephone Number

Work Home

 

Name and address of next nearest relative or trusted friend who could be contacted in an emergency:
Name Address

Telephone Number

Work Home

 

Health History

List any major operations or chronic illnesses or conditions you have experienced.

      

 


Name, Address and telephone number of physician(s):
Physician Address Telephone

 

Choice of hospital:  

 

Pharmacy Name:   Telephone: 

 

Medicare

# Part A: 

 

# Part B: 

 

Social Security No.:  (nnn-nn-nnnn)

 

Other insurance coverage: 

 

What assistance (if any) is required in the following areas?

  Area None Other Explain
a. Walking, Standing
b. Toileting
c. Bathing
d. Eating

 

Dietary Requirements:

a. Regular diet
b. Low sodium
c. Diabetic
d. Other

 

Current Medications: Dosage: Times Given:

Is supervision required?
       Yes  No  Explain (if yes)

 

Starting Date:    Frequency:

 

Days: Monday   Tuesday   Wednesday   Thursday   Friday

 

Transported by: Town  Family  Other

 

Assistance required:

 

What special needs does the applicant have? (i.e., Need for socialization, supervision, etc)

  

 

Name, Address and telephone number of individual or agency responsible for payment of Day Care services:

Name Address Telephone

 

I, as caregiver, agree/ do not agree to provide transportation to the Enfield Adult Day Center.

 

 

Signature of Responsible Party:  
   
Date:  

 

Instructions:

Note: Attach pages if more spaces are needed.

Complete application and E-Mail (with Submit, you will need to come in to sign the application) or print and mail to address at top of form.

 

After the application is received, the Director will call and set up an appointment for you to visit the Adult Day Center and for the client to be evaluated. The client must have a physical and a 2-step PPD or chest x-ray before beginning to receive services through the Day Center.