Enfield Adult Center Application
1A Beech Road, Enfield, CT 06982
Phone: (860) 763-7538 Fax: (860) 763-7584
Adult Day Care
Family and Personal Information
List any major operations or chronic illnesses or conditions you have experienced.
Choice of hospital:
# Part A:
# Part B:
Social Security No.:
Other insurance coverage:
What assistance (if any) is required in the following areas?
Starting Date: Frequency:
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:
I, as caregiver,
agree/ do not agree to provide transportation to the Enfield Adult Day Center.
Note: Attach pages if more spaces
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.