Adult Day Program - Programming Registration

This registration form is for current Circle of Care clients ONLY. If you are not currently a Circle of Care client, please connect with our Intake team by visiting https://www.circleofcare.com/info-referral/ and signing up for an appointment.

Name*
I would like to attend:*
What services of ours are you currently receiving?*
Have you used the online video conferencing platform ZOOM before?*
Do you have someone at home to help you use or set up ZOOM?*

AGREEMENT: You hereby acknowledge, confirm and understand that access and use of an online portal/online environment has some inherent privacy and security risks including, without limitation, risks that your information may be intercepted or unlawfully accessed. We want to make sure you understand this before you proceed with use of our online portal/online platform. In order to safeguard your privacy as well as your personal and other confidential information, you should take certain steps to reduce the risk of unauthorized access to your account and personal and other confidential information. First, you should only access and use our online portal/online platform and your account in a private setting and you should not use someone else’s computer/device as they may be able to access your account information and, possibly, your personal and other confidential information. Services will commence on the date shown on your file and can be terminated by you, within 24 hours cancellation notice at any time. Please be advised that the Circle of Care reserves the right to cancel or alter any program listed above in this form without notice and in its sole discretion for any reason whatsoever including, without limitation, insufficient registration numbers, change of policy, change of financial circumstances, technical issues and/or availability of instructors. *

*By checking this box, I confirm having read and understood and agreeing to be bound by the above terms and conditions.*
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