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 54701 Medical Connect Relationship Emergency 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 NeededDesired 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.
