Member Application

New Member Information

Member Applicant Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Lives With

Physician

Physician Phone

(###)

###

####

Hospital of Choice

Race (check one or more categories)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Ethnicity: (check one)

Hispanic/Latino

Non Hispanic/Latino

Contacts & Cell Numbers in Case of Emergency (1)

Call 1st: Name/Relation/Phone

Contacts & Cell Numbers in Case of Emergency (2)

Call 2nd: Name/Relation/Phone

Contacts & Cell Numbers in Case of Emergency (3)

Call 3rd: Name/Relation/Phone

Caregiver's Full Name

Caregiver Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Caregiver's Relationship to Member

Spouse

Adult Child

Other

Caregiver's Relationship to Member

Description, if "Other" is selected in previous question:

Send NEC fee invoices to:

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email (billing purposes only)

Email for other communications (if different from above):

Member Profile

The safety and comfort of your loved one is our top priority. Thus we have an in-depth application process, to ensure that our program is a good fit for your family member's needs. We appreciate your thorough and honest responses to the questions below, which will also be discussed in the intake interview. Information provided is for program use only.

Name

First Name

Last Name

Birthday

YYYY

Previous/Favorite Occupation

Family

Briefly describe his/her family so we may be able to ask about them (parents, siblings, spouse, or children):

Favorite Place(s):

Favorite Pastimes:

Medications

Please note that the Nelson Enrichment Club does not administer medications, and is not responsible for Members taking their medication. However, when dropping off your family member you can request a courtesy reminder by noting the medication and time taken on the Medication Reminder Sheet. Does your care partner take medication between 10am-2pm? If so, please describe below:

For safety reasons, please list any additional medications that your family member takes in the space below. Please note any medication allergies. Please note any major health issues, medical devices that we should be aware of. Should emergency care be needed, this list may be disclosed to first responders.

Falls

It is important to ensure that our environment is a safe place for your family member. Have they had any falls in the past 6 months? If so, please explain below:

Mobility

In order to be a good fit for our programming, your family member must be ambulatory (ie. able to walk, with or without an aid such as a walker or cane). Does your family member have any mobility issues and/or require assistance with walking, sitting, standing, etc? If so, please describe below:

Bathroom

In order to be a good fit for our programming, your family member must be able to toilet themselves. Supplies will be provided to address accidents. Our volunteers can provide an escort to the bathroom if needed; however, they are unable to accompany program participants into the bathroom or assist with toileting in any way. Does your family member require any assistance to use the toilet? If so, please elaborate below:

Safe and Comfortable Space

It is important to us to create a safe and comfortable space for all Members. Does your family member exhibit anger, aggressive or otherwise challenging behaviors? If so, please provide details.

Wander

Does your family member tend to wander? If so, please tell us more below:

Food Allergies

Does your family member have food allergies or dietary restrictions? If so, please note those below.

Any Additional Info?

Please note anything else you would like for the Nelson Enrichment Club to know about your family member:

Application checklist

Please complete each item below and then check each item below:

Provide thorough answers to the above questions

Read the Policies and Procedures Manual (available on website). Any questions you may have about our program can be discussed during a scheduled interview, prior to attending the Nelson Enrichment Club

Read and sign the three forms regarding enrollment, liability, and emergency medical care. If you are applying online, please also bring a signed copy of these three forms to your interview.

Either submit the application online, or mail to: Here to Stay, PO Box 138, Nellysford, VA 2 2958

Enrollment Contract

I, ____________ agree to the following regarding the enrollment process for the Nelson Enrichment Club. 1. The Program Director has explained the admission and enrollment conditions of the Nelson Enrichment Club so that I, ____________ understand them. 2. The Nelson Enrichment Club has provided me with a copy of the Policies and Procedures Manual, and I understand the contents and agree to adhere to all policies relevant to me. 3. I agree to inform the Nelson Enrichment Club in a timely manner of any changes pertaining to the Member, including health, mental, and physical status. 4. I agree to arrange or be available for prompt pick-up if my family member or loved one should become ill or disruptive. 5. I agree to keep my family member or loved one out of the Nelson Enrichment Club in accordance with the policy if he or she is feeling ill, particularly if he or she has fever, or has the flu, Covid, or any other contagious illness. 6. I agree to participate in family meetings when requested by the Nelson Enrichment Club staff. 7. I agree to notify the Nelson Enrichment Club staff in a timely manner if my family member or loved one will be absent from the program. 8. I agree that billing procedures will involve statements being sent to the responsible party on the 5th of the previous month. Payment is due within 10 days of receipt of the bill (ie. by the 15th of the month). Checks should be made out to Here to Stay Wintergreen. Please note in the memo line, “Nelson Enrichment Club program fees”.

Caregiver's Name

Caregiver's Signature

Participant's Name

Date

YYYY

General Release of Liability

In consideration of ____________________________ (hereinafter “Participant”) being allowed to participate in the programs, services, activities of the Nelson Enrichment Club program of Here to Stay Wintergreen (HSW), and to use the facilities of Rockfish Presbyterian Church and Rockfish Presbyterian Church Inc. (collectively “RPC), I, ______________________________, as personal representative, legal guardian, next of kin, care giver, or as holding power of attorney for Participant, on behalf of Participant, his or her heirs and assigns and for myself and my heirs and assigns, do hereby unconditionally remise, release, and forever discharge and covenant not to sue the Club, HSW, RPC, and any of their officers, pastors, session members, board members, agents, employees, members and volunteers including other participants (collectively, the “Releasees”) from any and all actions, causes of actions, suits, debts, charges, complaints, claims, liabilities, obligations, promises, agreements, controversies, damages of all and any kind, of any nature whatsoever, in law or in equity, whether for death, personal injury, property damage or otherwise, (collectively, the “Claims”), arising or resulting from or in any way relating to my or Participant’s participation in the programs, services, activities, and facilities of the Releasees, which I or the Participant or our heirs and assigns have, may have had, may hereafter have, or may be entitled to assert against each or any of the Releasees regardless of whether I or Participant knows, should have known or had reason to know of the Claims on the date hereof. I, for myself and on behalf of Participant, our heirs and assigns, further agree to indemnify and hold harmless the Releasees from any and all Claims, or liability of any kind arising from our participation as aforesaid. Without limiting the generality of the foregoing and for the absence of doubt, this Release of Liability shall apply fully to Participant’s attendance on any field trips, engagement in any exercise program or physical activity provided by the Club, or from any incident in which the Participant leaves the program site without permission.

Participant Name

Legal Guardian Name

Signed

Personal Representative/ Legal Guardian/ Next of Kin/ Power of Attorney, Etc. Note: Please provide copy of power of attorney or other document evidencing legal authority to sign on behalf of participant.

Dated

YYYY

Consent for Emergency Medical Care

As a participant in the Nelson Enrichment Club of Here to Stay Wintergreen (HSW) at the Rockfish Presbyterian Church (RPC), I hereby give permission to staff (paid and volunteers) to provide direct emergency care for minor emergencies or to access 911 emergency medical services as deemed necessary. I hereby give my full and unconditional approval for said staff to secure emergency medical care. In the event of a medical situation, whether or not an emergency, staff may request that a doctor see the Member. It is understood that the Member cannot return to the program without a report concerning the incident. Any resultant bill(s) will be the sole responsibility of the Member and/or caregiver/guardian. Said individual(s) will be responsible for filing any and all medical insurance claims. I will not hold any of the staff (paid or volunteer) of HSW or RPC responsible for any injury which occurs to the named participant during the course of the program (including without limitation on any field trips or exercise programs). Furthermore, I acknowledge that HSW and RPC cannot and do not assume responsibility for any undesirable incidents or injuries should the participant leave the program site without permission.

Participant's Physician's Name

Participant Physician's Phone

(###)

###

####

Hospital of Choice

Participant's Name

Legal Guardian Name

Signed

Dated

YYYY

Please, complete each of the following fields. When finished, please select the “Submit” button.