Caregiver Application

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

Disclaimer and signature

Agreement:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. I consent to having my references contacted to ascertain my appropriateness to provide Adult Family Care Services.