Healthcare Adult Day Program Form

Healthcare Adult Day Program Enrollment & Consent Form

Participant Name:   Preferred Name:

Participant Information

Male    Female    Other   

Emergency Contacts & Authorized Representatives

Healthcare Providers & Insurance

Medical History & Functional Status

Mobility / Transfer Status: Ambulatory, independent Uses cane Uses walker Wheelchair Requires transfer assistance

Continence: Independent Needs assistance

Behavioral, Safety & Communication

Behavioral / Safety Concerns: (check all that apply) Wandering/elopement Aggression Frequent falls Self-harm risk

Program Services, Medication & Transportation Consent

The Adult Day Program provides social, recreational, therapeutic, and health monitoring services during scheduled program hours. Participation in program activities is voluntary. Participants retain the right to withdraw at any time, subject to program discharge policy. By signing below, Participant or Authorized Representative consents to participation in routine program services, therapeutic activities, and basic care as outlined in program materials.

Medication Administration: I authorize program staff to administer or assist with medications that are prescribed by an authorized prescriber, following written directions and in original labeled containers. I will provide an up-to-date medication list and notify staff of any changes. I understand the program will document administration and report medication errors or adverse events to the primary care clinician and emergency contact as required.

Transportation: I authorize the program and its contracted providers to transport the participant to and from program activities as scheduled. I understand transportation is provided subject to availability and program policies. I release the program and its employees from liability for ordinary negligence in the provision of transportation services, except where prohibited by law.

Photo/Video & Information Release

I consent to the program taking and using photographs or video of the participant for documentation, program records, and internal educational purposes. I understand images will not be used for commercial advertising without separate written consent.

Authorization for Release of Health Information: I authorize the Adult Day Program to disclose and receive protected health information about the participant to/from treating providers, emergency responders, insurance payers, and authorized representatives as necessary for care coordination, payment, and program operations. This authorization includes verbal and written communications, and copies of medical records when required.

Emergency Medical Treatment & Liability Release

In the event of an emergency, I authorize program staff to provide first aid and to seek emergency medical treatment for the participant, including transport to a hospital and necessary medical interventions. I understand the program will make reasonable efforts to contact the emergency contact and authorized representative. I accept financial responsibility for medical services provided by emergency medical personnel and hospitals. The program and its staff will not be liable for costs incurred in providing emergency care except as required by law.

Fees, Attendance & Termination

I agree to pay program fees as established in the program fee schedule. I understand fees may apply for no-shows or late cancellations. The program reserves the right to suspend or terminate services for nonpayment, failure to follow program policies, or when the program determines it cannot safely meet the participant’s needs. The program will provide notice of termination and coordinate transition planning when feasible.

Acknowledgment & Consent

By signing below, I certify that the information provided on this form is complete and accurate to the best of my knowledge. I authorize the Adult Day Program to provide services described herein and to exchange necessary information with the persons and entities listed above for the purpose of coordinating care. I understand I may revoke this authorization in writing, except to the extent that action has already been taken in reliance on it.

I acknowledge receipt of the program's policies on participant rights and privacy practices and understand my rights regarding my health information and program participation.

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