Membership Registration Applicant Information(Please type or print clearly)Facility Name*Facility Physical Address*City*State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip*County*Facility Telephone*Facility FaxFacility Email Facility Website*Licensee*as shown on facility licesnseContact InformationContact Name* First MI Last Contact TitleExecutive Director/CEO level?*YesNoContact Mailing Address*Contact City*Contact State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingContact Zip*Email*This email address will be associated with your website login credentials Enter Email Confirm Email Contact TelephoneContact FaxFacility InformationFor Providers OnlyLegal StructureNon-Profit CorporationGovernmentalFor-Profit Corporation For-Profit StructureLLC (Limited Liability Company)ProprietorshipPartnershipJoint VentureHow did you first learn about KAAD?KAAD Office/Staff sent information (mail/fax/email)KAAD Web SiteKY Department of Aging Office/StaffKY Department of Social Services Office/StaffReferralWho were you referred by?Person and organization who referred you Kentucky Association of Adult Day Centers, C/o American Health Management, PO Box 572, Richmond, KY 40476 Telephone: (859) 623-4080 Fax: (859) 624-5771 Membership InformationPlease indicate the membership category for which Applicant qualifies. (See Membership Categories and Dues Schedule or contact KAAD for assistance at (859) 623-4080) Select a membership category*Provisional Provider (non-voting)Licensed Provider (voting)Associate Member (non-voting)Individual Member (voting)Test Transaction (no membership)Check all program types that apply ADC (Adult Day Care) ADCRC (Alzheimer’s Day Care Resource Center) ADSC (Adult Day Support Center) ADHC (Adult Day Health Care) Date license submitted* Date Format: MM slash DD slash YYYY Month and Year Licensing Anticipated:*Do you operate multiple centers?*If Yes, a separate application for each center must be completed.YesNoADHC Licensed* Date Format: MM slash DD slash YYYY ADHC Capacity*ADC Licensed* Date Format: MM slash DD slash YYYY ADC Capacity*Fiscal Year Ends*Month & YearRevenue*$1 – 199,000$200,000 – 299,999$300,000 – 399,999$400,000 – 499,999$500,000 – 599,999$600,000 – 699,999$700,000 – 799,999$800,000 – $899,999$900,000 – 999,999$1M – 1.49M$1.5M – 1.99M$2.0M – 2.49M$2.5M – 2.99M$3.0M – 3.49$3.5M +Description*Associate Membership Classification*Choose oneVendorConsultantAllied OrganizationOut-of-State ProviderGovernmental/Non Adult Day Services EntityBusiness offering products/services to the adult day services industry.Business offering start-up or operational consulting services to adult day service providers but that does not directly provide adult day services. Health or Social Services organization not operating an adult day services program and not in the process of licensure. Examples: Nursing home, hospital, residential care facility for the elderly, board and care, physician practice, managed care, intermediate care facility, home health agency, etc.Adult day services provider located out-of-state with no adult day services operations in Kentucky.Community based long-term care organizations, association, or network not directly providing adult day services. Examples: Area Agency on Aging, governmental department/agency, educational institution, planning council, etc.An applicant may qualify under this category when he/she directly provides adult day services and each center is currently a member. Annual Dues $0.00 Consent*I certify that the contents of this application are accurate and complete and will advise the association of significant changes in operations, ownership, or material changes to the membership information. I agree to abide in the Bylaws, and policies of the association including decisions of the Membership committee and other duly constituted KAAD Committees. I agree that membership may be terminated immediately if application contains false or misleading statements. I agree to the following termsNameThis field is for validation purposes and should be left unchanged.
