Caregiver Application

Fill out the form below to submit your application electronically, or download a fillable PDF and email it to ckushmerek@asncm.org and rnevalsky@asncm.org once completed.

Download the Fillable Form

Contact Information
Housing Information
Employment Information
Personal References
Review & Submit

Fields with * are required.

Applicant's Contact Information

Last Name *

First Name *

Middle Initial

Date of Birth *

Home Address *

Town *

Zip Code *

Home Phone *

Business Phone

Your Email Address *

Consumer Email

How did you hear about the AFC program?

Contact Information
Housing Information
Employment Information
Personal References
Review & Submit

Fields with * are required.

Housing Information

Directions to your home: give directions to locate your home from some main highway or the center of town and some identifying features of your house *

Number of floors *

On which floor is the participant's bedroom? *

Size of participant's bedroom *

Number of bathrooms *

How many people use participant's bathroom? *

Do you have liability and fire insurance for your home? *

Do you have another source of income? *

Please list all family members living in your home *
Include their name, age, relation to you, and time regularly spent out of home

Please list other persons living in your home *
Include their name, age, relation to you, and time regularly spent out of home

Contact Information
Housing Information
Employment Information
Personal References
Review & Submit

Fields with * are required.

Employment Information

Are you presently working? *

If so, type of employment *

What is your work schedule? *

Is your spouse working? *

If so, type of employment *

What is your spouse's work schedule? *

Do you or your spouse have physical limitations or are you presently under the care of a physician for treatment of a condition? *

What experience have you had in the care of elderly, frail, or disabled persons? Describe those experiences. *

Why are you interested in participating in this program? *

Contact Information
Housing Information
Employment Information
Personal References
Review & Submit

Fields with * are required.

Personal References

Please name three references (not related to you) whom we may contact, one of whom is your family doctor.

Reference #1

Name *

Address & Zip Code *

Relationship to you *

Phone Number *

Fax Number

Email *

Reference #2

Name *

Address & Zip Code *

Relationship to you *

Phone Number *

Fax Number

Email *

Reference #3

Name *

Address & Zip Code *

Relationship to you *

Phone Number *

Fax Number

Email *

Contact Information
Housing Information
Employment Information
Personal References
Review & Submit

Fields with * are required.

You can use the Back buttons to review your answers.

I hereby authorize the Adult Foster Care Program of Aging Services of North Central Massachusetts to make an inquiry with the above persons relative to my character and qualifications to care for an older person in my home.

Signature *
By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Date *