Franciscan Adult Day Center

Costs & Apply

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Day Care is less expensive than private, in-home care, or residential care!

 

Fees:
$60.00 per day

Continental breakfast, a nutritious, hot lunch, frequent beverages, and a healthy snack will be provided each day. Our dietician can provide special meal requests or medically prescribed diets. All meals are no added salt and no concentrated sweets. Meals are delivered hot each day from a local caterer.

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Application Procedure

1)  Please fill out the online application below.  We will review your application information and assess our ability to meet your family member’s needs during a visit. (A good fit between the participant and the day care program is crucial to success!)

Date of Application:
Learned about SMILE from:
Your First Name:
Your Last Name:
Your Email Address:
   
Participant's First Name:
Participant's Last Name:
Address:
City:
State:
Zip:
Phone:
Birth Date:
Social Security Number:
Gender:
Birthplace:
Ethnicity:
Marital Status:
Single   Married   Divorced   Widowed
Languages Spoken:
Education:
Occupation:
Living Arrangement:
Diet Restrictions
Special Needs:
None     Assist with Walking    Cane     Eyeglasses    Hearing Aid
High Riser    Walker     Wheelchair    Assist with Toileting
Other    Specify:
In-Home Services:
None    Visiting Nurse    Companion Aide    Homemaker Services
Bathing Service    Meals on Wheels    Hospice    Home Health
Other    Specify:
Transportation:
HandiVan    Family
Physicians:
Name #1:
Phone:
Address:
Name #2:
Phone:
Address:
Most Recent Hospitalization:
Reason:
Person responsible for payment / funding sources:
Name:
Phone:
Address:
Emergency Contacts:
Name #1:
Relationship:
Address:
Phone:
Name #2:
Relationship:
Address:
Phone:
Name #3:
Relationship:
Address:
Phone:
Primary physical and mental health problems:
Medications:
Medication Name #1:
Amount:
Frequency:
Purpose:
Medication Name #2:
Amount:
Frequency:
Purpose:
Medication Name #3:
Amount:
Frequency:
Purpose:
Allergies:
Skills/Interests:
If participant was not in this center, what would happen to him/her?
Participant will attend Franciscan Adult Day Center on the following days:
Monday     Tuesday     Wednesday    Thursday     Friday
Date of Enrollment:
First Day of Attendance:
Last Day of Attendance:
Comments:

 

2)  We require a physician to complete a health and physical form and present documentation of a clear TB test given within the last 3 months. The State of Hawaii requires physician approval and TB clearance prior to admission and renewed annually thereafter.

PDF IconClick here to download the Health & Physical form.

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3)  Call our center at 808-988-5678  to set up an appointment for you to come and visit us. We encourage you to bring your family member with you at this time.

Attendance in our program can begin immediately upon completion of these three steps.  Mahalo for choosing Franciscan Adult Day Center! 

 

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