AFC Electronic Application Submission

1Application Information

2Education/Profession

3Household

4Physical Setting

5References

6Statement of Understanding

7Authorization and Release

References
By signing below, I hereby authorize the Multicultural Community Services, Adult Foster Care program to make inquires with the following references in relation to my character and the qualifications to care for a person in my home.
Signature of applicant:*
Today's Date:*
Please note that references cannot be relatives. References may be friends, co-workers, business associates, etc. We prefer at least one reference be a current or past employer.
Reference #1:
Name:*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number:*
Type of relationship:*
Known for how long?*
Reference #2:
Name:*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number:*
Type of relationship:*
Known for how long?*
Reference #3:
Name:
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone Number:
Type of relationship:
Known for how long?

Authorization and Release
I/we give permission for the release of any information to a prospective member that would be helpful in matching the member’s needs to my/our caregiver capabilities.
Signature of Applicant:*
Today's Date:*
If you do not have a spouse or partner please check the N/A box otherwise a signature from them is required:
- N/A
Today's Date:*
Signature of Spouse/Partner:*
If you do not have another adult over the age of 18 please check the N/A box otherwise a signature from them is required:
- N/A
Today's Date:*
Signature of Other Adult Members of household (over 18 years)*

Multicultural Community Services of the Pioneer Valley, Inc.

Name:	Age:	Relationship to you: