VACANCY LOG   APPLICATION FORM

TO BE INCLUDED IN THE VACANCY LOG PLEASE PROVIDE THE FOLLOWING INFO
 (Copy and Paste Form into Email Below - then FILL IN and Send   -  One Form Per House)

AFH Name: Phone
Provider's Name/s:
Email Address:
Website:
Mailing Address
Street Address
City: Zip:
WSRCC CHAPTER: Clark County Chapter WSRCC Year 1st Joined WSRCC:
Circle the highest professional license held:       ARNP      RN      LPN      NAC      NAR      Other:
Year Licensed: Years Experience: Staffing Level - Days: Staffing Level - Night:
# Vacancies:
 		 Capacity:
 		 Allow Smokers?
 		 Pets in Home? Describe:
 		 Pets Allowed? 
 
Services           Y/N                  Y/N                  Y/N                           Y/N                  Y/N              Y/N                     M/W/E
Offered:          Hospice          Respite          Mental Health          Dementia          DD          Medicaid          Men/Women/Either     
Primary Language:                                                Secondary Languages:
Interested in the next issue of the ADULT FAMILY HOME'S guide?  Y   /   N
Do you already have your page designed?  Y   /   N
Do you need help updating the page in the current AFH guide?  Y   /   N
Do you need a complete page designed including taking pictures?  Y   /   N

There is a cost involved for designing your page and pictures to be taken on location that will be determined upon need basis by the designer at a rate of $45/hr.
PRICE ESTIMATE TO PARTICIPATE IN THE NEXT ISSUE OF AFH IS $500.00
 ***(this does not include designing the add/page)***

Interested in a Website presence?                         Y / N                                    Y / N                                              Y / N        
 Please circle:                                          Website you can manage            Website We Manage            One Page w/Photos
Preferred Domain Name (or Website address): WWW.
Comments:

(CHECK ONE):         [  ]  I am a member           [  ]  I am becoming a member
                      of WSRCC AFH Association and wish to receive the benefits of membership 2006-2007. 
                     Signed:                                                                                                                    Date:                                           

Adult Family Home's guide information will be collected at the next Chapter Meetings
or visit www.AFHCatalog.com or e-mail Dorina@AFHCatalog.com.

Copy and Paste this Form into email below, then FILL-IN & send by
     Email:  chris@ed-webdesigns.com            or       Fax: 425-608-2825      
     Call Chris Moss at 425-608-0099 with questions.
                                                          Don't forget - include your digital photos with your email!