Forms
If after reading about our program you feel that the Civitan Adult Day Program would
be a good fit for your family member, scroll to the bottom of this page to download
the initial enrollment forms.
The following is a full list of items you will be asked to produce and complete
for the full Civitan Adult Day Program enrollment Process:
1. Submit a completed Civitan Services application along with the following items:
- Last Psychological Evaluation
- Copy of Social Security Card
- Copies of Medicaid/Medicare Cards
- Copies of Insurance cards.
- Copy of Driver's License or photo ID
- Immunization Record
- TB skin test (within the last 12 months)
- Legal guardianship papers/Power of Attorney papers if client is not his/her own guardian
- For individuals age 21 or younger, a copy of his/her diploma or letter of Completion.
- Current photo of individual.
2. The Adult Services Director will schedule a tour of the facility (if one has
not already taken place)
3. Releases will be completed and signed by the individual and/or guardian.
4. Individual will be asked to get a new physical examination from their primary
physician and have a temporary IHP signed prior to admission but less than 30 days
old.
5. A start date is set and transportation to and from the Civitan Center will be
scheduled if needed.
6. A new psychological evaluation may be requested based upon the date of the last
evaluation.
Adult Application Checklist
Adult Application
Adult Home Page