Spend The Day With Us - Daybreak Shelby County

We’d like to extend a welcome to senior residents of Shelby County to spend the day with us.
Just complete the brief questionnaire below, and we will be in touch with you to confirm your visit to DayBreak.

Intake Form

Participant Name*
First Last
This would be the person coming to DayBreak
Participant Address*
Street Address Address Line 2 City State ZIP Code
Family/Caregiver Name*
First Last
Family/Caregiver Address*
Street Address Address Line 2 City State ZIP Code
Family/Caregiver Email*
Mobile Phone*
For use in case of emergency
Work Phone
For use in case of emergency
Toileting*
- Independent - Can do themselves
- Need someone to supervise
- Needs hands-on assistance
Please indicate the level of assistance needed
Eating*
- Independent - Can do themselves
- Needs someone to supervise
- Needs hands on assistance
Please indicate the level of assistance needed
Walking*
- Independent - Can do themselves
- Needs someone to supervise
- Needs hands on assistance
Please indicate the level of assistance needed
Is there any adaptive equipment necessary for the participant?
Are there any cognitive/intellectual impairments

i.e. Alzheimers, Dementia
Any other comments about the participant that you'd like to share?
I attest that the information provided is true to the best of my knowledge and hereby waive DayBreak Adult Day Services from any liability for any accident/ injury. Submission of this form is acceptance of the same.