About You

Applicant's Full Name(Required)

First Last

Your Address

Street Address Address Line 2 City ZIP Code

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Date of Birth:(Required)

Sex:(Required)

Male

Female

Medicaid Number:

Information About Applicant

Why are you interested in coming to this program?(Required)

Have you had previous experience in a Day program?(Required)

Yes

If yes, where and when?(Required)

Do yoμ· have any personal ooncerns or Information that,may impact on our provision of care to this participant(Required)

Yes

If Yes, Please Explain:(Required)

Emergency care Information

Please list the names of two persons who may be contacted In case of emergency:(Required)

First Last

Name & Relationship to Applicant(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Second Emergency Contact(Required)

First Last

Name & Relationship to Applicant(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Name of Physician:(Required)

First Last

Physician's Phone:(Required)

Edens Promise Adult Day Tralnlng Appllcatlon for Enrollment Services and Agreements

Transportation will be provided by: Relative or Friend?(Required)

Yes

Edens Promise ADT Transportation

If yes, please provide name, address and telephone number:(Required)

Edens Promise ADT Transportation(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Arrival Time(Required)

Departure Time(Required)

Special dietary needs, if any:

(Attach a copy of the doctor's orders If on a therapeutic diet) Supportive devices used by applicant: 1. This participant does not require a POA, may make his/her own medical or other decisions, and may sign for his/herself legally. Yes/No. If yes, please list information below.

1. This participant does not require a Power of Attorney, may make his/her own medical or other decisions, and may sign for his/herself legally.(Required)

Yes

2. Participant (named below) has a Power of Attorney or legal guardian (POA document shown)(Required)

First Last

Phone(Required)

Participant has a DNR order:(Required)

Yes

If yes, please provide documents. I will provide the day program with an original copy.

DNR Original Copy

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 256 MB.

The validated staff will administer medications, If needed, as prescribed. I will provide these medications in the containers as dispensed with their proper labeling as per state requirements. All medications will be locked and distributed at time prescribed.(Required)

Yes - To confirm you have read and understand the above statement

It Is the responsibility of the participant and/or responsibility·party to notify the Center of any changes in medication, health conditions, etc.(Required)

Yes - To confirm you have read and understand the above statement

I have received a copy of my Participants Rights in my enrollment packet.(Required)

Yes

Edens Promise ADT Adult Day Training Enrollment Application. Please check the boxes choose Yes or No to acknowledge you Completely understand. If you choose no, please STOP this application process and call our office at 772-203-7521.

I agree to adhere to the program requirements by having an annual physical and tuberculin skin test or physician verification of being free of communicable disease. The results will be maintained as a part of my confidential program health records.(Required)

Yes

I hereby authorize/ not authorize the Edens Promise Adult Day Training to use my pictures, videos, slides or tape recording of me for publicity; our in-house photo album and/or news releases relating to the Edens Promise Adult Day Training.(Required)

Yes - I Authorize

No - Not Authorized

I hereby authorize Edens Promise Adult Day Training to take photographs and create a “scent-pack” to be confidentially maintained and used only for identification purposes. I authorize my name with these forms of identification.(Required)

Yes - I Authorize

No - Not Authorized

Other

All items brought to the center must be marked. Edens Promise ADT Training will not be held responsible for missing or lost items.(Required)

Yes

If emergency medical care becomes necessary, I give permission for any treatment the physician deems necessary.(Required)

Yes

The day program's policies have been explained to me, and I have been given a copy of them and agree to abide by them. If not, please contact us via e-mail or phone.(Required)

Yes

I acknowledge that I have received Edens Promise Day Training's Notice of Privacy Practices. I understand that the notice and disclosures of my protected health information by Edens Promise ADT Adult Day Training Informs me of my rights and respect of my protected health information. A signed authorization and specifics regarding the release of information will be signed at each information request, when indicated by law.

Applicant Signature:(Required)

Responsible Party Signature:(Required)

Witness Signature:(Required)

Date(Required)

Edens Promise ADULT DAY TRA1N1NG MEDICINE LIST: please list if taken at program: Frequency, time of day, medication will be taken.

To be prepared for the emergencies that can and do happen, please list below all medications being taken either at the Center or at home by the participant. This will provide the rescue squad with the vital medical information that is necessary to administer proper treatment. It is important that the staff at the Center be given in writing any changes in medication to keep our records current.

I hereby authorize the personnel of Edens Promise ADT to administer the medicine(s) listed below. In doing so, I hereby release said program, its officers, staff and, personnel from all liability might arise because of the medication being administered and hereby waive any action which I may have as a result-of the medication being administered. I will be notified when the medicine supply is low. Furthermore, I release the fore said from any and all liability that might arise because of said medication not being administered because the supply was not replenished.

Over-the-counter medication(s) ordered by Physician: (Physician’s order with dosage & instructions are required):(Required)

Allergies:

State regulations prohibit administering any medication not in the original container from the doctor or pharmacy. STATE OF FLORIDA LAW under medications kept by the program shall be in containers in which they were dispensed from the pharmacy. 65-G, the containers shall be clearly labeled with the participant's full name, the name and strength of the medicine, and dosage and instructions for administration. Only medications that meet this stated criterion will be given. Most pharmacies will give two containers if asked. Pills brought to the center in envelopes, pill boxes or other containers not meeting the above description cannot be given. Edens Promise ADT must have any over the counter medications be accompanied by a physician's order when dispensed at the program. With everyone’s safety in mind, It is necessary to strictly comply with this policy. It is not intended to be a hardship on anyone. Thank you for your cooperation.

Participant's Signature:(Required)

Date(Required)

Guardian/Medical POA's Signature:

Date(Required)

Media Release Form

1. I, (print name below statement 4) (Model, Actor/Subject/etc., hereafter, the "Releasor") for good and valuable consideration, the adequacy of which Is acknowledged, with the understanding that Edens Promise Adult Day Training Center (the •Releasee") will invest substantial time and expense to produce certain audio and/or visual works in reliance upon this document. does hereby consent to participation in said production and to being personally identifiable in the resulting media, regardless of production method or type of media, including without limitation, digital and analog photography, film and videography (with or without sound), and audio recordings (the “Media") whether captured or created by Releasee directly, or by those under Releasee's direction.

2. Authorization and Waiver, Releasor authorizes the universal and unrestricted reproduction of their voice and/or licenses in connection with the use or manipulation of the Media by Releasee, Releasee's heirs, successors, assigns, and designees, and those acting with Releasee's permission and authority, in any form now existing or yet to be invented, for all purposes, including, without limitation, streaming, film, television, other forms of transmission, advertising, art_ promotion, solicitation, or trade. Additionally, Releasor waives any right to approve the eventual use or purpose to which the Media may be applied; or to inspect or approve the finished images, videos, advertising copy, artwork, materials. or other audio or visual matter resulting from the Media's implementation, use, or manipulation, whether in its original form or processed, altered, blurred, distorted, combined with, or used in conjunction with any other media, and will hold Releasee, Releasee's heirs, successors. assigns, and designees harmless and indemnify same against any claims or demands arising therefrom.

3. Entire Agreement. This agreement constitutes the sole and complete agreement between Releasor and Releasee and shall be governed by the laws of the state of Florida. Releasor is not relying on any other warranty, guarantee, or representation, whether oral or written. By signing this release, I affirm that I am of the age of majority and have the right to contract in my own name OR- if Releasor is a minor, that I have the right to contract in their name and on their behalf. I have read this entire document, understood its contents, and agreed to the rights and responsibilities it defines for each party. This agreement shall be binding upon me and my heirs, legal representatives and assigns.

Name of consumer(Required)

First Last

Signature and Date (If Releasor is a minor, a parent or guardian must sign and date)(Required)

Printed Name and Phone Number (If Releasor is a minor, parent or guardian must complete)(Required)

Edens Promise Adult Day Training Transportation Agreement

I, (Name of Parent) give permission for Edens Promise ADT Center (provider). or any approved of the above program, to transport (Name of Consumer) for the following reasons. (check All that apply below after entering names)

Name of parent(Required)

First Last

Name of consumer(Required)

First Last

Check all that apply for ADT Transportation(Required)

Field Trips

Community outings related to ADT

Excursions to the park

Any reason deemed necessary by the program

It is agreed that 1. The caregiver will never leave anyone unattended in any motor vehicle or other form of transportation. 2. Each consumer will board or leave a vehicle from the curb side of the street. 3. Consumer will be secured in safety seats or by safety belts as appropriate for the age of the Adult in accordance with the law. 4. Any motor vehicle used to transport will have current registration and inspection stickers and must be operated by a person who is at least 18 years of age and possesses a valid driver’s license.

Parent or Guardian Signature(Required)

Date(Required)

Provider/Director Signature

Date

Release of Liability for Emergency Medical Assistance Edens Promise Services ADT

I, (Print Name Below Statement), acknowledge and understand that Edens Promise ADT prioritizes the safety and well-being of all Individuals in its care. In the event of a medical emergency, staff members will take necessary actions, including but not limited to contacting 911 emergency services to obtain immediate medical assistance. By signing this release, I agree to the following terms: 1. Emergency Medical Assistance: I authorize Edens Promise ADT staff to seek emergency medical assistance, including calling 911, in the event of a medical emergency. 2. No Liability for Medical Costs: I acknowledge that Edens Promise ADT shall not be responsible for any medical expenses, ambulance fees, hospitalization costs, or any other charges incurred because of seeking emergency medical assistance on my behalf or on behalf of my dependent. 3. Assumption of Risk: I understand that medical emergencies can be unpredictable, and while Edens Promise Services ADT will act in good faith to provide timely assistance, it cannot guarantee specific medical outcomes. 4. Release of Claims: I hereby release and hold harmless Edens Promise Services ADT, its staff, employees, and affiliates from any liability, claims, or financial responsibility related to the medical assistance provided or any expenses Incurred as a result. 5. Responsibly for Medical Expenses: I acknowledge that any costs associated with emergency medical services are my sole responsibility or that of my insurance provider. I agree to make any necessary arrangements for payment with the medical provider directly. I have read, understood, and agree to the terms of this Release of Liability. I sign this document voluntarily and acknowledge that I have the legal authority to do so.

Participant/Guardian Name:(Required)

First Last

Participant/Guardian Signature:(Required)

Date(Required)

Emergency Contact Name:(Required)

First Last

Emergency Contact Phone:(Required)

By signing this document, the participant (or legal guardian) acknowledges the responsibility for any medical expenses inaarred and releases Edens Pro,rilse ~rvices ADT from any related liability.

For Office Use Only

Staff Witness Name:

First Last

Staff Witness Signature:

Date

Adult Day Training Application

About You

Information About Applicant

Emergency care Information

Edens Promise Adult Day Tralnlng Appllcatlon for Enrollment Services and Agreements

Media Release Form

Edens Promise Adult Day Training Transportation Agreement

Release of Liability for Emergency Medical Assistance Edens Promise Services ADT