Trial Stay Reservation Request for JIM’s Suites "Required" indicates required fields Guest NameRequired First Name Last Date of Birth (MM/DD/YYYY)RequiredMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the guest a member of an Adult Day Program?Required Yes No Not Sure Which Acclaim Health Adult Day Program do they attend?RequiredWalmley ClubSoper ClubBurlington ClubMississauga ClubAnother Adult Day ProgramWhich one?RequiredPlease provide us with any details you think we should know about their experiences in their Adult Day Program:Guest DetailsDiagnosisRequired Alzheimer’s Dementia Vascular Dementia Lewy Body Dementia Other Guest's Home AddressRequired Street Address Address Line 2 City Province Postal Code Main Phone NumberRequiredSecondary Phone Number (optional)Does the guest currently live in a retirement home?Required Yes No Retirement Home NameRetirement Home Phone NumberGuest ExperienceWhat do we need to know about this guest to make their stay enjoyable?RequiredPlease provide information on their physical abilities, cognitive abilities, bedtime routine, allergies, medications, care and supervision needs, behaviour concerns, language(s) spoken, communication needs, interests. This can brief, you’ll have a chance to discuss your guest’s needs with our team as well.Has the guest stayed in a respite facility in the past?Required Yes No Not sure If yes, please provide the name of the respite facility:Please provide us with any details you think we should know about their past respite stay(s):Caregiver Contact InformationWho will be the primary contact person during the guest’s stay?Name of Primary ContactRequired First Last Main PhoneRequiredSecondary Phone (optional)EmailRequired Relationship to GuestRequiredThe Primary Contact Person is:Required Power of Attorney (POA) Substitute Decision Maker (SDM) None of the above Referral InformationWho is completing this reservation request?Use the Caregiver Contact Information from above Use the Caregiver Contact Information from above Your NameRequired First Last Daytime Phone NumberRequiredEmail Relationship to guest:Required Spouse Adult Child Family Member Friend Professional Other Your Job TitleYour OrganizationPermissionsPermission to SubmitRequiredAcclaim 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. I agree CAPTCHA