Katie Adult Day Center Participant/Caregiver Acknowledgement Form

I/we have received a copy of the Adult Day Centers policies and procedures
including:
Policy/procedure: Initials:
Scope of programs, services, and care offered
Description of population served
Description of conditions the center is not prepared to accept for
service
The ADS Bill of Rights
Grievance Procedure including the contact number for the DHS
Licensing Division
Vulnerable Adults Act and MAARC Reporting
Policy and Arrangements for Transportation
Policy on providing Snacks and Meals
Fees, billing arrangements, and plans for payment
Policy governing pets in the Center
Policy on smoking in the Center
Types of Insurance Coverage carried by the Center
Statement that Center admission and employment practices and
policies comply with MN Statutes, Chapter 363, the MN Human
Rights Act
Terms and conditions of the centers licensure by the DHS
If this ADS provider markets or otherwise promotes services for
persons with Alzheimers disease or related disorders, a
description of the training program, the categories of employees
trained, the frequency of training, and the basic topics covered.

I have received the above initialed written policies and procedures.

I have received a written notice of the right to contest the accuracy and
completeness of data maintained in my ADS record.
Signed: ____________________________________________ Date: ___________
ADS Staff Member: __________________________________ Date: ___________

Katie Adult Day Center Policies and Procedures Manual 05-003.16