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Contact
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+1(781)388-1115

Apex > Caregiver Application

Caregiver Application

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182 Sylvan St, Malden, MA 02148
Tel. (781)388-1111, Fax (781)388-1110

Primary CaregiverAlternate Caregiver

Name

DOB

SexMaleFemale

Address:

City

State

Zip

SS#

Telephone:

Language

How did you hear about the program:

Do you own a car?YesNo

Are you willing to provide transportation to the member?YesNo

Plan to transport member(s) to medical appointments:

Do you have any medical or psychiatric limitations that might prevent you from rendering hands on assistance to the member(s)YesNo

If Yes (please specify):

Last physical exam date:

TB Test date and finding:

What is your relationship to the potential member(s):

Number of individuals you are interested in caring for in your home:123

Are there any pets in the home:YesNo

If yes please list:

Does anyone smoke in your home:YesNo

Please list all members and non-relatives living in your home, including yourself:

Name

Age

Relation to caregiver:

Please list 3 references

Full Name:

Relationship:

Email

Phone

Address:

Disclaimer and signature

Agreement:

The information on this application is complete and accurate. I authorize investigation of all statements on this application as is necessary in arriving at a contracting decision. I understand that misrepresentation or omission of facts called for is cause for immediate termination of any contractual agreement.
I agree to allow a home study evaluation and inspection of my home to ascertain my qualifications and eligibility to provide Adult Family Care Services.
I consent to a Criminal Offender Record Information (CORI) and Sex Offender Registry Information (SORI) investigation as part of the application process and authorize further CORI and SORI
investigations during the contract for myself and others who would support a placement with me and Apex. I understand that the Apex Adult Foster Care Human Resources Dept. follows many CORI and SORI regulations and policies as we support very vulnerable populations, and our CORI and SORI checks are very detailed.
I consent to an Office of Inspector General check to see if I am on the exclusion list from participation in federal health care programs. If I am found on this list, I will not be able to
participate in AFC.
I understand that prior to contractual agreement, I must obtain a written statement from my licensed health care provider regarding my health based on a physical and TB test within the past year. I understand I must have a TB test or screening and physical every two years thereafter.
I consent to having my references contacted to ascertain my appropriateness to provide Adult Family Care Services.

Caregiver Applicant Signature:

Date:

Organization

is registered under the provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, or current licensees. As a prospective or current employee, subcontractor, volunteer, license applicant or current licensee, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to

Organization

to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my
signature. I may withdraw this authorization at any time by providing

Organization

with written notice of my intent to withdraw consent to a CORI check.

I also understand, that

Conduct (Organization)

__________________________________________________may subsequent CORI checks within one year of the date this Form was signed by me.

By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.

Signature of CORI Subject

Date

First Name:

Middle Initial:

Last Name:

Suffix (Jr., Sr., etc.):

Former Last Name 1:

Former Last Name 2:

Former Last Name 3:

Former Last Name 4:

Date of Birth (MM/DD/YYYY):

Place of Birth:

* Last SIX digits of Social Security Number:

No Social Security Number

Sex:

Height:

Eye Color:

Race:

Driver’s License or ID Number:

State of Issue:

Father’s Full Name:

Mother’s Full Name:

Current Address

* Street Address:

Apt. # or Suite:

*City:

*State:

*Zip:

SUBJECT VERIFICATION

The above information was verified by reviewing the following form(s) of government‐issued identification:

Verified by:

Signature of Verifying Employee Date

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info@apexafc.com
Phone: +1(781)388-1115
Fax: +1(781)388-1110
182 SYLVAN ST, MALDEN MA 02148

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