Report an Adult Day Program Absence Client Name * Required First Last Caregiver Name * Required First Last Caregiver Email * Required Start Date of Absence * Required DD dash MM dash YYYY Last Date of Absence * Required DD dash MM dash YYYY Adult Day Program Location: * Required Burlington Club Mississauga Club Soper Club (Patty's Place, Oakville) Walmley Club (Patty's Place, Oakville) Reason for Absence * Required Sick - Enteric (stomach flu, diarrhea) Sick - Respiratory (cold, cough) Sick - Other COVID-19 (confirmed or suspected) Refusing to Attend Fatigued Medical Appointment Family Commitment Other Would you like a staff member to follow up with you? * Required Yes No Permission to Submit * Required I agree Acclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you.CAPTCHA
