Ill. Admin. Code tit. 77, pt. 330, subpt. R, app C, form A
SAMPLE
APPLICATION FOR DAY CARE
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 | ______________ | ________________ | |||||||||||||||
DOYOU HAVE TRANSPORTATION? | _________________ | ||||||||||||||||
Ill. Admin. Code tit. 77, pt. 330, subpt. R, app C, form A