DINING CENTER ENROLLMENT FORM

Use this form to enroll a new participant at the Dining Center. Complete the form, make a copy for your permanent record, then send the enrollment to Highland Valley. A sample of the form is below.

Check “New”, “Termination”, “Change” or “One Time Meal” as appropriate.

Effective Date: For new participant, fill in today’s date.
For termination or change, fill in date termination or change takes effect.

Meal Type: Check the appropriate box for a Regular or Diabetic Meal.

D.C. Code: Enter the code for your Dining Center from the Code Chart.

D.C.C. Initials: Enter your initials

Name: Participant’s full name

Address:
City: Participant’s complete address
Zip:

Telephone: Participant’s phone number

Date of Birth: Participant’s Birth Date. If no birth date is listed, the participant can not be enrolled

Sex: Check “M” for male, “F” for female

Minority Code: Check “Asian”, “Black”, “Cape Verdian”, “Hispanic”, Alaskan Native/American Native. Check nothing if Caucasian.

Please remember that this is the method to use to terminate clients who no longer come to the center. If you would like them to be removed from the computer sheets, fill in the name and be sure to check “Terminate” on the top of the form.