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* 1. Participant Name:

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* 2. Completed By:

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* 3. Upon reopening, all Spend-A-Day staff will wear Personal Protective Equipment (PPE), follow infection prevention protocols and complete COVID-19 screening. It has not been announced yet by the State of NJ if the vaccine will be required for staff and/or participants to return. Knowing this, do you anticipate that your loved one will return to Spend-A-Day?

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* 4. If not returning, what is the reason?

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* 5. Has the participant received the COVID-19 vaccine?

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* 6. If yes, which brand & how many doses? 

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* 7. We anticipate capacity restrictions and may not be able to honor the participant's previous attendance schedule. How many days per week would you like them to attend?

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* 8. Previous attendance schedule:

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* 9. Are you able to provide transportation if bus transportation is not immediately available? 

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* 10. Please list any questions/concerns about reopening. We hope to receive reopening information from the State of NJ soon, and we will continue to update you as we receive the information. If you need more space, please email Demi Pavlakos, Social Worker, at dpavlakos@sageeldercare.org 

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