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Rec & Roll Adult Day Program Interest Form

Rec & Roll Adult Day Program Interest FormSteve Eckelberry2023-04-26T09:45:03-05:00

Rec & Roll Interest Form

For new families interested in joining the Rec & Roll Adult Day Program.

Step 1 of 4

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Rec & Roll Adult Day Program Interest Form

New participants are welcome to join WDSRA’s adult day program, Rec & Roll at any point throughout the year. WDSRA offers several locations within our day program to meet the needs of our communities and families. Each location, and ratio, has specific participation requirements that must be met to be considered for the program. The Day Program Assistant Managers will assess and determine which program best meets the needs of each individual interested in the day program. New participants may be placed on a waitlist until a spot becomes available and are subject to a assessment period upon entry. Please complete the form below to help our staff learn more about your participant and the day program you are interested in. Our Day Program Assistant Managers will get back to you within 1 week of your inquiry. NOTE: Residents will receive priority on waitlist before non-residents.

Contact Information

Interested Participant's Name(Required)

Address(Required)

Rec & Roll Interest

Rec & Roll has a total of 7 different locations. Please rank the locations based on the ratio and location you most prefer. 1 = Most interested, 0 = Not the appropriate ratio.

To view which Rec and Roll program is the best fit, view the eligibility criteria here

1:3 Ratio Sites

Fountain View, Carol Stream
Fort Hill, Naperville

1:6 Ratio Sites

Carol Stream
Glen Ellyn
Naperville
Wheaton
Winfield

Preferred Number of Days(Required)
Select the number of days per week which you are interested in having your participant attend Rec & Roll.
Preferred Attendance Dates(Required)
Select all days of the week which you are interested in having your participant attend Rec & Roll.
Transition Contact(Required)
If your participant is still in/has recently graduated from transition, can we have permission to contact his/her teacher?
If applicable: please provide us with the contact's name and email/phone number

Participant Information

Please complete the following to give us a better understanding of your participant
Communication(Required)
How does your participant communicate
Mobility(Required)
Social Interaction(Required)
Following Directions(Required)
Assistance(Required)
Does your participant need any assistance with the following
Please explain the level of assistance needed
Please Select All That Applies(Required)

Thank you for your interest! A Day Program Assistant Maanger will contact you within 7 business days of the form being submitted.

NOTE: Regardless of your preferred start date, you may receive a phone call earlier about an open spot. Declining a spot could move you to the bottom of the waitlist.

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116 N. Schmale Road
Carol Stream, IL 60188-2103
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