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(916) 899 - 6166
daycationforseniors@yahoo.com
6011 Stanford Ranch Rd. Ste. 105 Rocklin, CA
Mon - Fri: 08:00 AM - 5:30 PM
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Home
Why daycation for seniors
About Us
Management
Volunteer
Gallery
Daily Schedule
Membership
Testimonials
Contact
Franchise
Login
Tour Registration
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Tour Date
Daycation Experience (4 hrs.)
Date
Start Date
Participant’s name
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Age
Primary Diagnoses
Responsible Person’s Name
Relationship
Phone
Cell
Email
*
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Second Contact Person
Relationship
Phone
Physician Name
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Neurologist Name
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How did you hear about us?
Facebook
LinkedIn
Del Oro Resource
Seniors First
Event
Doctor
Neurologist
Drive by
Support Group
Hospice
Discharge Planner
Alzheimer's Association
Word of Mouth
Online Search
Other
Participant’s Interest
Mobility
*
Wheelchair
Walker
Cane
Can walk about the facility unassisted
Do they need assistance in the bathroom?
*
Yes
No
Have they ever wandered off unannounced from anywhere?
*
Yes
No
Do they take medication while at Daycation?
*
Yes
No
Any dietary restrictions?
*
Yes
No
Please list dietary restrictions
Vision
*
Peripheral Only
Wears Glasses
Blind in Right Eye
Blind in Left Eye
Hearing
*
Hard of Hearing
Wears Hearing Aides
Deaf
Notes
Preferred hospital in case of emergency
*
Sutter Roseville
Kaiser Roseville
Mental Health
Is anxiety a problem?
*
Yes
No
If yes, how often?
Less than 1x a week
Less than 1x a day
Once a day or more
Participant’s Personality
Introvert Type
Extrovert Type
Submit
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