AFC Caregiver Application.

Please complete the form below to be a Caregiver

Primary Caregiver * First Last
Spouse of Partner First Last
Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Mailling Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Number * - ### - ### ####
Home Number - ### - ### ####
Business Number - ### - ### ####
Email Address *
Will you be caring for a family member in your home? *
Yes No
If “Yes”, what other supports/services are being provided in the home? Examples may include DDS, PCA, VNA, Meals On Wheels, Hospice, Adult Day Health *
Do you have liability/fire insurance coverage or renter’s insurance for your home? *
Yes No
Do you have a working Classing ABC fire extinguisher in your home? *
Yes No
Do you have a carbon monoxide detector on each level of your home? *
Yes No
Do you have an emergency first aid kit in your home? *
Yes No
Are you able to provide three meals and two snacks per day for the participant, as needed? *
Yes No
Are you able to provide three meals and two snacks per day for the participant, as needed? *
Yes No
Would you be willing to provide a modified diet if required for a particular participant? *
Yes No
Do you have a private bedroom available for the participant? *
Yes No
Do you have furniture available? If so, please list the items available for use.
Do you have pets in the home? *
Yes No
If yes, list pet(s) below
Please list all family members/ individuals living in your home including Age, Relationship and Time Spent away from Home. *
A CORI check is required, initially and every two years, for all family members living in the home 18 years and over
Have any of the individuals listed above had at any time a history of court involvement? *
Yes No
If yes, please explain
Are you currently Employed? *
Yes No
If yes – please state type of employment and current schedule
*AFC participants cannot be left alone in the home more than three hours under any circumstances
Is your spouse or partner working? *
Yes No
If yes – please state type of employment and current schedule:
Do you have any physical or psychological limitations that would affect your ability to care for a participant living in your home? *
Yes No
If yes, briefly explain
Do you have any experience in helping to care for an elderly, frail or disabled individual? *
Yes No
If yes, briefly describe your care-giving experience
Why are you interested in participating in this program? *
Please provide contact information for the three references below
Physician Name * First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Telephone * - ### - ### ####
Employer Name First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Telephone - ### - ### ####
Character Reference * First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Telephone * - ### - ### ####
Reference forms will be sent to these three references, along with your completed Reference Release Form.
ADULT FOSTER CARE REFERENCE RELEASE FORM
Caregiver Applicant * First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Telephone * - ### - ### ####
I give permission for the release of any information that would be beneficial in evaluating my ability to serve as a caregiver from my physician, my employer and my listed character reference. I understand that this information can be obtained via mail, fax, email or telephone. I understand that all information obtained will be confidential and will not be made available to any other person or agency without my consent. *

Clear
Date / MM / DD YYYY

AFC Caregiver Application.

AFC Caregiver Application.

A CORI check is required, initially and every two years, for all family members living in the home 18 years and over

*AFC participants cannot be left alone in the home more than three hours under any circumstances

Please provide contact information for the three references below

Reference forms will be sent to these three references, along with your completed Reference Release Form.

ADULT FOSTER CARE REFERENCE RELEASE FORM