New Participant Application
Boca Raton Adult Daycare · 2120 N. Dixie Highway, Boca Raton, FL 33431 · 561-299-0417 · PFAdultDayCareCenter@gmail.com
Please print clearly in blue or black ink. Do not write full Social Security numbers or payment card numbers on this form.
Participant
Participant full name
Preferred name
Date of birth
SSN (last 4 only)
Gender
Marital status
Living condition
Preferred language
Home address
Participant phone
Email
Caregiver / Responsible Party
Name
Relationship to participant
Phone
Email
Emergency Contacts
Contact 1 — name
Relationship
Phone
Contact 2 — name
Relationship
Phone
Authorized pickup (names & phones)
Program & Schedule
Program requested
Requested start date
Days per week (3-day minimum)
Transportation needed (Yes / No)
Memory support needed (Yes / No)
Veteran (Yes / No)
Clinical Information
Medical conditions / diagnoses
Allergies
Mobility status
Dietary restrictions
Current medications (attach list)
Primary physician
Physician phone
Pharmacy / phone
Payer & Insurance
Payment method
Insurance company
Member ID
Policy number
Group number
Billing contact
Acknowledgements
- Adult Day Care requires a minimum of 3 days per week.
- A $75 one-time Registration Fee applies at initial enrollment (non-refundable). A $250 Behavioral Deposit applies when required by assessed needs (non-refundable).
- Program, registration, and transportation fees are non-refundable. Cancel 48+ hours before a scheduled day for an account credit; under 48 hours or no-show forfeits the day.
- Boca Raton Adult Daycare is a social adult day care center and does not provide skilled nursing, therapy, medication administration, or medical treatment.
- The center is closed on the last Thursday of every month.
Participant / responsible party signature
Date
Printed name
Relationship
Center staff received by
Date received