New Member Enrollment forms

Step 1 of 7

Enrollment Application

Basic information about the participant and their caregiver.

Caregiver / Responsible Party

Caregiver Name *

Home Phone

Cell Phone *

Email Address

Will someone be home at pickup & return time?

Yes
No — participant stays alone / has community status

Emergency Contacts

Please provide two emergency contacts.

Contact 1

Name *

Relationship

Address

Home Phone

Cell Phone *

Other useful info

Contact 2

Name

Relationship

Address

Home Phone

Cell Phone

Scheduling & Referral

Days Attending

Transportation Provided By

How did you hear about us?

Case Manager Phone (if applicable)

Reason for Referral

Step 2 of 7

Social History

Background information to help us provide personalized care.

Personal Background

Birthplace

Languages Spoken

Education

Employment History

Veteran?

Yes
No

Branch / War Served

Church / Religious Affiliation

Anniversary Date

Number of Children

Children’s Names

Interests & Activities

Past Interests / Hobbies

Current Interests / Hobbies

Activities they’d like to learn with ADC staff help

Other useful information about the participant

Psychosocial Status

Select all that apply for each characteristic.

Step 3 of 7

Health & Daily Living

Medical providers, health history, medications, and daily living abilities.

Medical Providers

Primary Physician

Physician Phone

Physician Address

Dentist

Dentist Phone

Eye Doctor

Eye Doctor Phone

Preferred Pharmacy

Pharmacy Phone

Activities of Daily Living (ADLs)

D = Dependent | SI = Semi-Independent | I = Independent

Task	Level	Task	Level

Step 4 of 7

Medical Emergency Plan

Emergency procedures and preferred medical facilities.

Emergency Procedure Plan

Preferred Hospital

Preferred Clinic

Primary Physician & Phone

Known Allergies (medications, latex, etc.)

I also grant staff of A Home for the Day to administer basic first aid should a minor injury occur, or initiate CPR.

Medical Information Release

Authorize Release From (Provider 1)

Authorize Release From (Provider 2)

Authorize Release From (Provider 3)

I also authorize verbal and/or written exchange of my medical information with the above listed providers.

Do NOT release records from alcohol or drug abuse treatment programs under federal law.

Step 5 of 7

Consents & Agreements

Please read and indicate your consent for each item below.

Photograph Release

Program Use — may my picture be used on bulletin boards and memory albums at the facility?

Yes
No

Promotional Use — may my picture be used for brochures, publications, social media, or educational programs?

Yes
No

Data Privacy

I have read and understand the Data Privacy policy described above.

Participant Service Agreement

I have read and agree to the Participant Service Agreement described above.

Step 6 of 7

Policy Documents

Please download and review each document, then check to confirm you have received and understood it.

Acknowledgement of Receipt

In compliance with the Minnesota Vulnerable Adults Act, you must be oriented to the following documents within 24 hours of admission.

Participant Handbook

Covers program policies, daily schedule, meals, activities, and your rights as a participant.

📄 Download Handbook PDF

I have received and read the Participant Handbook.

Vulnerable Adult Act Summary

Minnesota Statutes §245A.65 and §626.557 — your protections against maltreatment and how to report concerns.

📄 Download Vulnerable Adult Act Summary PDF

I have received and read the Vulnerable Adult Act Summary.

Program Abuse Prevention Plan

Describes how A Home for the Day prevents and responds to abuse of participants.

📄 Download Abuse Prevention Plan PDF

I have received and read the Program Abuse Prevention Plan.

Maltreatment of Vulnerable Adults Reporting Policies

Explains mandatory reporting requirements and how reports are handled under Minnesota law.

📄 Download Maltreatment Reporting Policies PDF

I have received and read the Maltreatment of Vulnerable Adults Reporting Policies.

Can the participant sign legal documents?

Yes
No — someone will sign on their behalf

Step 7 of 7

Review & Sign

Please read the statement below, then sign to complete your intake forms.

Participant / Caregiver Signature

Printed Name *

Relationship to Participant

I confirm that the signature I am about to provide is my own act and is attributable to me as the authorized signer for this participant.

Signature *— draw with your finger or mouse

Sign here

Your signature, printed name, relationship, date, and exact time of submission are recorded to meet Minnesota electronic signature requirements (§325L.09).

Today’s Date *

Staff Information

To be completed by A Home for the Day staff at or after admission.

ADC Staff Representative

Information Obtained From

ADC Observations / Comments

A Home for the Day — New Member Intake

Enrollment Application

Social History

Health & Daily Living

Medical Emergency Plan

Consents & Agreements

Policy Documents

Review & Sign

A Home for the Day — New Member Intake Summary

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