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NYC Office of Actuary NYC Department for the Aging
         
* = These Fields are required.

Social Adult Day Care (SADC) Registration Form

Directions:

All New York City Social Adult Day Care programs must register with the Department for the Aging pursuant to Local Law 9 of 2015. Questions related to the registration form may be sent to sadc-ombuds@aging.nyc.gov. Programs must submit only ONE registration per program site.


SADC Program Site Information


  (e.g.123456789)
/ /

  (e.g.(123) 456-7890)

  For Hours of Operation,   (e.g.09:00-05:00)
Mon Tues
Wed Thurs
Fri Sat
Sun

  eg. 1234
Yes No
(If answer is no, please explain)
Yes   No  

SADC Director Information

 

  (e.g.(123) 456-7890)

Corporate Structure

Non-Profit Corporation/LLC
Individual/Sole Proprietor
Joint Venture
Partnership/LLC Single Member LLC
Other  
Check here if same as Program Site Address listed above
Check here and enter address if different
     

Ownership Information

Provide the name(s), title(s), phone number(s) and e-mail address(es) for each owner. *Not applicable to/required for not-for-profit SADC entities.
,

  (e.g.(123) 456-7890)

Managed Long Term Care Company

List the Managed Long Term Care company(ies) (MLTC) that the SADC has formal agreement(s) with. Please be sure to specify the full name, address, and telephone number of each MLTC listed. If there are more than 10 contracted MLTCs, click here to enter the additional company(ies).

  (e.g.(123) 456-7890)

Acknowledgement and Signature

  1. Registrant affirms that he/she is authorized by SADC to provide the information on this registration form.
  2. Registrant acknowledges that changes to information provided under this registration must be submitted to the Department for the Aging no later than the effective date of such change by submitting a SADC Notification of Change Form.
*
I Agree.
* *

Please enter the letters or numbers in the order as they appear. NOTE: There are no spaces between the numbers and if you are having issues with the Captcha, please click on the Refresh Image and try again

Registration copies must be printed PRIOR to submission of the completed registration. Confirmation/acknowledgment of registration receipt will include a unique ID number, and will be emailed ONLY to the Director listed under SADC Director Information.