Ill. Admin. Code tit. 77, pt. 300, subpt. U, app D, form A
SAMPLE
APPLICATION FOR DAY CARE
FORM A
NAME ________________________ AGE ___________ BIRTH DATE ______________
ADDRESS ____________________ PHONE __________________________________
___________________________ SOCIAL SECURITY NUMBER _________________
MEDICARE NUMBER _______________________
WITH WHOM DO YOU LIVE? _______________________________________________
RELATIONSHIP? ________________________________________________________
PERSON TO CONTACT IN AN EMERGENCY __________________________________
ADDRESS ____________________________________
PHONE __________BUSINESS PHONE_____________
PHYSICAL LIMITATIONS (please list) | 1. _________________________ |
2. _________________________ | |
3. _________________________ | |
4. _________________________ |
SPECIAL PHYSICAL NEEDS (medications during day, special rest periods, etc. please list)
1. _____________________ | 4. ____________________ |
2. _____________________ | 5. ____________________ |
3. _____________________ | 6. _________________________ |
MEDICAL PROBLEMS (circle)
1. diabetic | 8. hearing |
2. subject to seizures | 9. eyesight |
3. heart disease | 10. assistance with meals |
4. dizziness | 11. any paralysis |
5. urinary control problem | 12. difficulty in walking |
6. bowel control problem | 13. periodic confusion |
7. special diet | 14. allergies (list) |
15. others |
ARE YOU PRESENTLY UNDER A DOCTOR'S CARE? __________________________
NAME AND ADDRESS OF PHYSICIANS | __________________________ |
__________________________ | |
__________________________ | |
__________________________ | |
SPECIAL INTEREST OR HOBBIES | __________________________ |
__________________________ |
DAYS ENTERED IN PROGRAMMING
A.M. | P.M | |
Monday | _____________ | _____________ |
Tuesday | _____________ | _____________ |
Wednesday | _____________ | _____________ |
Thursday | _____________ | _____________ |
Friday | _____________ | ___________________ |
DO YOU HAVE TRANSPORTATION? ______________________________
Ill. Admin. Code tit. 77, pt. 300, subpt. U, app D, form A