New Member Registration Form3410 Sky Park Blvd Eau Claire, WI 54701-7090info@ rellimseniordaycare.com715-600-0746Monday - Friday 7am - 5pm Saturday - Sunday CLOSEDPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastAgeEmail *Phone Numberex. 715-123-4567Addressex. 123 Main St, Eau Claire, WI 54701Emergency Contact & Relationshipex. Jane Hill, SisterName of Person Completing FormBest Time to ConnectMedical History *List any chronic conditions or medical diagnoses.Functional Assessment *Any assistance necessary with daily activities? Such as, dressing, toileting, bathing, feeding, transferring, etc.Nutritional Status *Dietary restrictions and feeding assistance needs.Safety Needs *Any fall risks or history of falls?Schedule Preference--SELECT OPTION----SELECT OPTION--Full-Time (5 days a week)Part-Time (1-4 days a week)Casual/As Needed Safety Number Relationship Desired Start DateAny other pertinent information or comments?Submit Thank you! At Rellim, we believe in personalization. We tailor activities to suit each senior's unique preferences, personality, and physical capabilities.
