Day Center Online Application A physical copy of our application is available on property if you have any difficulty with the online format. Step 1 of 8 12% Thank you for your interest in Ho’oNani Day Center! In order to qualify for our program, your loved one must be able to function in a group setting without aggression or verbal disturbances.* Checking this box acknowledges your understanding that should their behavior become unmanageable, their physical condition require skilled nursing care, or 1:1 personal care become necessary, withdrawal from the program will be requested. Today's Date The following section pertains to the participant applying for Ho’oNani Day Center.Name of Participant First Last Physical Address of Participant Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address of Participant Same as physical address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of ParticipantSex of Participant Male Female Date of Birth of Participant MM slash DD slash YYYY Age of ParticipantLanguage of Participant Marital Status of Participant Living Arrangements of Participantex. Spouse, Child, Independently Email Address of Primary Caregiver* Emergency Contact(s)Please list personal emergency contacts in order of responsibility (use plus symbol to add additional fields)NameRelationshipDaytime PhoneCell Phone Medical InformationPrimary Physician Name First Last Name of Practice Practice Location City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Physician PhoneOther Providers:(use plus symbol to add additional fields)Provider's NameLocation Diabetic: Yes No Seizures: Yes No List Any Food Allergies(use plus symbol to add additional fields) List Any Drug Allergies(use plus symbol to add additional fields) Special Dietary Requirements Yes No If Yes, please explain:Special Devices/Equipment(check all that apply) Glasses Walker Hearing Aid Wheelchair Dentures Prosthesis Cane Catheter Other If Other, please explain:Please describe current and past medical problems and disabilities:Please list all medications participant is currently taking:(use plus symbol to add additional fields)NameDosageFrequencyTime Given Service RequestHow did you learn about Ho’oNani Day Center?(Please include all referrals)Please select the days that you prefer to attend Ho’oNani Day Center(please check all that apply) Monday Tuesday Wednesday Thursday Friday Saturday Community ContactPlease list any social service agencies with which the participant has had contact within the past 12 months(use plus symbol to add additional fields)Agency NamePhone NumberReason for Service FinancesPlease list the person responsible for payment of your bills:Name First Last Relationship Email address to send invoices to PhoneSignatureAre you the applicant (client), family member (non power of attorney) or do you have the power of attorney for the applicant?Primary applicantPower of attorneyFamily (non power of attorney)Name of Family member and/or Power of Attorney First Last Applicant SignatureIf you are unable to sign the document on your computer or device, you can sign a physical copy on property at a later date.Signature of Family member and/or Power of Attorney Admission PoliciesThese policies are important to keep the business flowing smoothly and the environment kept safe.In applying for admission to HoʻoNani Place, dba HoʻoNani Day Center, the applicant and responsible party accept to conform to the following policies: Private payments must be made at the beginning of the month in the full amount due. Payments are non-refundable with the exception of loss of life, a contagious medical condition, hospitalization or emergency closures of the center. Days may be switched if 1) it is within the same calendar month of the date missed, and 2) if we have an opening available. Should a client move into long-term care before the end of a calendar month, two weeks notice must be given. Reimbursement will be granted for any remaining days left in the calendar month after that two week window. Each participant’s physician must complete a medical evaluation verifying that the participant is free of communicable disease, and has had a negative tuberculin skin test within the past 90 days. (form provided by HoʻoNani Day Center,) Participants’ medications shall be in up to date pharmacy-labeled bottles and kept in a locked cabinet at HoʻoNani Day Center. The participant’s physician must sign an authorization statement for staff of HoʻoNani Day Center to administer medication. The participant will not be allowed to attend the program if he/she is ill or is considered infectious by HoʻoNani personnel. If a health emergency arises while at HoʻoNani Place the family will be notified. If necessary, the participant will be transported to a hospital by the family, or by an ambulance obtained by HoʻoNani Day Center at the family’s expense. Should the family’s personal physician be unavailable, one will be selected and contacted by our staff. Admission and continuance in the program is subject to the approval of the participant, the family, and the administrative staff of HoʻoNani Day Center. If the participant’s behavior becomes unmanageable, their physical condition requires skilled nursing care, or 1:1 personal care is required, withdrawal from the program will be requested. The participant must be picked up by closing time, or there will be a late pick-up fee of $10.00 for the first 10 minutes, and $5.00 every 10 minute increment thereafter. HoʻoNani Day Center is not responsible for any valuables or money kept in the participant’s possession.Admission Policy Acknowledgement* I acknowledge I have read the policies above Release of LiabilityIn consideration of my acceptance as a participant in the adult day care programs and services offered by HoʻoNani Place, LLC, I, the undersigned, for myself, my heirs, personal representatives, estates, administrators and assigns, hereby waive and release any and all claims for damages, for death, personal injury, loss of property or property damage I may have, or that may subsequently accrue to me, or to my heirs, personal representatives, estates, executors, administrators or assigns, against HoʻoNani Place, LLC, its officers, owners, managers, members, employees, agents, representatives and staff, including any unpaid volunteers, arising from or as a result of my participation in such programs and/or my receipt of any such services provided by HoʻoNani Place, LLC, its employees, representatives, staff and/or unpaid volunteers. I acknowledge that as a result of the limitations in my ability to care for myself without assistance, my care and custody, and my participation in various activities, involves known and unknown risks of accidents and injuries as a result of the acts, conduct and/or omissions of other participants and/or the employees, staff and/or volunteers of HoʻoNani Place, LLC. Knowing such risks and agree to indemnify, release and hold harmless all of the persons and entities described above who may or might be liable to me (or my heirs, personal representatives, estates or assigns) for damages. My participation in the adult day care programs and services offered and provided by HoʻoNani Place, LLC, is voluntary and done at my own risk. I hereby consent to receive medical treatment which may be deemed advisable in the event of my injury, accident or illness while at HoʻoNani Place, LLC, but I understand and agree, however, that medical or other services rendered to me by, or at the instance of, any of the persons or entities described above is not an admission of liability to provide waiver by any or the persons or entities described above of any rights under this Waiver and Release. If a health emergency arises while at HoʻoNani Place, the family will be notified. If necessary, the participant will be transported to a hospital by the family, or by an ambulance obtained by HoʻoNani Place at the family’s expense. Should the family’s personal physician be unavailable, one will be selected and contacted by our staff. I agree to accept and abide by the rules and policies of HoʻoNani Place, LLC, as established and provided to me from time to time. I have read this Waiver and Release and fully understand its contents. I am aware this Waiver and Release is a release of liability and a contract between myself and HoʻoNani Place, LLC, for the benefit of the persons and entities described above and I voluntarily sign this Waiver and Release of my own free will.Applicant SignatureIf you are unable to sign the document on your computer or device, you can sign a physical copy on property at a later date.IF THE PARTICIPANT IS UNDER THE CARE OF CUSTODY OF A GUARDIAN, THE SIGNATURE OF THE GUARDIAN OF THE PARTICIPANT IS REQUIRED:I undersigned Guardian of the participant named above hereby represents that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnity each and all of the persons and entities described above from all liability, losses, costs, claims or damages whatsoever which may be imposed upon said persons and entities because of any defect in or lack of such capacity to so act and release and discharge said persons and entities as above stated on behalf of the participant named below.Guardian SignaturePower of Attorney Signature Social MediaHo'oNani Adult Care Services, Inc will be using paper and social media to increase awareness of it's services to the general public. This venture is in hopes that more caregivers needing the care of HoʻoNani Place, LLC will have access to information about it's services, as well as find a place to learn tips and find support during their caregiving phase of life. Photos taken at HoʻoNani may be used to demonstrate the activities and joy experienced by our clients. Please acknowledge below if you approve of a photo being used that you are in. Yes, I approve of my photo being used in paper and social media that is directly associated with Ho'oNani Adult Care Services, Inc. No, I do not approve of my photo being used in paper and social media that is directly associated with Ho'oNani Adult Care Services, Inc. Who I AmThis final section helps us get to know who your loved one is, as a whole person. Providing as much detail as possible helps us to understand and connect with them!Family HistoryPlace of Birth Name of Mother Name of Father Number of SiblingsBrothersSisters Married? Yes No Name of Spouse(s) or Life Partner(s)Names of Children and GrandchildrenEducation & Work HistoryYears of Education Area of Study Primary Occupation Other Jobs HeldYear Retired Veteran Yes No Other Information:CAPTCHAThank You for Completing This Application in Detail.
