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.


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