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OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION Child Nutrition Services Old Capitol Building, PO BOX 47200 OLYMPIA, WA 98504-7200 AGREEMENT NUMBER Child and Adult Care Food Program ADULT DAY CARE
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How to fill out adult day care agreement

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Who needs adult day care agreement?

01
Adult day care centers: Adult day care centers may need an adult day care agreement to establish a formal agreement between the center and the individuals receiving care. This agreement helps outline the terms and conditions of the services provided.
02
Caregivers: Family members or caregivers who are responsible for coordinating adult day care services may need to fill out an adult day care agreement. This document helps ensure that all parties involved are aware of their responsibilities and obligations.
03
Individuals receiving care: Those who will be attending the adult day care program may also need to participate in filling out the agreement. This allows them to understand the rules, regulations, and expectations set forth by the adult day care center.

How to fill out adult day care agreement:

01
Basic Information: Start by providing the necessary basic information, such as the name of the adult day care center, the participant's name, address, contact information, and the date the agreement is being filled out.
02
Services Provided: Specify the services that will be provided by the adult day care center. This may include activities, socialization opportunities, transportation, meals, and medical assistance if applicable. Clearly outline the days and hours of operation as well.
03
Participant Responsibilities: Explain the responsibilities of the participant to ensure their cooperation and adherence to the rules and regulations of the adult day care center. This may include punctuality, respectful behavior, and following the instructions of staff members.
04
Privacy and Confidentiality: Address the privacy and confidentiality of the participant's personal information. Assure them that their personal information will be kept confidential and used only for the purpose of providing appropriate care and services.
05
Fees and Billing: Clearly state the fees associated with the adult day care services and explain the payment schedule. Include information on any financial assistance programs or insurance coverage that may be available.
06
Termination of Services: Specify the conditions under which either party can terminate the agreement. This may include non-payment, violation of rules, or changes in the participant's care needs. Include any necessary notice periods for termination.
07
Signatures: Provide spaces for the participant and, if applicable, their legal representative or caregiver to sign and date the agreement. This ensures that all parties have read and understood the terms of the agreement.
08
Review and Updates: Clearly state that the agreement is subject to review and updates as necessary. This allows for changes in services, fees, or any other relevant information that may arise in the future.
Remember, it is always advisable to seek legal advice or consult with professionals experienced in creating adult day care agreements to ensure that all necessary legal requirements are met and the agreement is thorough and appropriate for your specific situation.
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Adult day care agreement is a contract between a caregiver facility and an adult participant outlining the terms of care and services provided.
The caregiver facility is required to file the adult day care agreement.
You can fill out the adult day care agreement by providing all necessary information about the participant and the services to be provided.
The purpose of the adult day care agreement is to establish the terms of care and services provided to the adult participant.
The adult day care agreement must include information about the participant's medical needs, dietary requirements, and emergency contacts.
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