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Professional Resident Information Sheet template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
TEMPLATE • Inspection-Ready AFH Standard
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
Base Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
Provider Signature / Date
Resident / POA Signature / Date
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Full legal name, preferred name, DOB, SSN, primary language, and religious preferences.
Primary/secondary POA contacts, legal guardian papers, and financial guarantor info.
Doctor name, clinic address, phone, preferred hospital, and contracted pharmacy.
Known allergies, primary medical diagnoses, transfer assistance level, and diet type.
Or get this form included in the Operations & Records Bundle ($69)