Alternative Family Living Provider Application

How to Complete and Submit the Alternative Family Living Provider Application

You can fill out the application using the form below. Follow each step to ensure your application is submitted correctly.

Need Help?

If you have any questions or encounter issues, please call us at 252-654-4800 or email HRHinc0615@gmail.com. We’re here to help!

Alternative Family Living Provider Application

Herbert Reid Home, Inc. – Alternative Family Living (AFL) Provider Application.

Step 1 of 9

Name

This field is for validation purposes and should be left unchanged.

Alternative Family Living Provider Application

Applicant #1 Information

Applicant #1 Name(Required)

Prefix First Last Suffix

Applicant #1 Maiden Name

Applicant #1 Marital Status(Required)

Applicant #1 Gender(Required)

Applicant #1 Religious Preference (if any)

Applicant #1 Primary Language(Required)

Applicant #1 Address(Required)

Street Address City State ZIP Code

Cell Phone(Required)

Home Phone(Required)

Email(Required)

Enter Email Confirm Email

Applicant #2 Information (if applicable)

Applicant #2 Name

Prefix First Last Suffix

Applicant #2 Maiden Name

Applicant #2 Gender

Applicant #2 Religious Preference (if any)

Applicant #2 Marital Status

Applicant #2 Primary Language

Applicant #2 Address

Street Address City State ZIP Code

Cell Phone

Home Phone

Enter Email Confirm Email

Persons Living in Household (including self)

Household Member #1

Member #1 Name (First and Last)

Member #1 Birthdate(Required)

Member #1 Sex

Member #1 Relationship to Applicant(s)

Member #1 Race

Member #1 Ethnicity

Member #1 Last 4 Digits of SSN

Household Member #2

Member #2 Name (First and Last)

Member #2 Birthdate

Member #2 Sex

Member #2 Relationship to Applicant(s)

Member #2 Race

Member #2 Ethnicity

Member #2 Last 4 Digits of SSN

Household Member #3

Member #3 Name (First and Last)

Member #3 Birthdate

Member #3 Sex

Member #3 Relationship to Applicant(s)

Member #3 Race

Member #3 Ethnicity

Member #3 Last 4 Digits of SSN

Household Member #4

Member #4 Name (First and Last)

Member #4 Birthdate

Member #4 Sex

Member #4 Relationship to Applicant(s)

Member #4 Race

Member #4 Ethnicity

Member #4 Last 4 Digits of SSN

Household Member #5

Member #5 Name (First and Last)

Member #5 Birthdate

Member #5 Sex

Member #5 Relationship to Applicant(s)

Member #5 Race

Member #5 Ethnicity

Member #5 Last 4 Digits of SSN

Does anyone else live on your property?(Required)

Yes

Do you rent your own property?(Required)

Yes

Residency (Past 5 Years)

Have you lived in North Carolina, consecutively, for the past 5 years?(Required)

Yes

Previous Addresses (if No above)

List previous addresses for each applicant for the last 5 years. Add more sheets if needed.

Applicant #1 Previous Address

Enter your complete Previous Address below

Date from

Date To

Applicant #2 Previous Address

Enter your complete Previous Address below

Applicant # 2 Date from

Applicant # 2 Date To

Certification & Signatures

Primary Contact Signature (type full name)(Required)

Primary Contact Signature Date(Required)

Secondary Contact Signature (type full name)

Secondary Contact Signature Date

Alternative Family Living Provider Application

How to Complete and Submit the Alternative Family Living Provider Application

Alternative Family Living Provider Application

Alternative Family Living Provider Application

Applicant #1 Information

Applicant #2 Information (if applicable)

Placement Preference

Persons Living in Household (including self)

Household Member #1

Household Member #2

Household Member #3

Household Member #4

Household Member #5

References

Reference #2

Reference #3

Residency (Past 5 Years)

Previous Addresses (if No above)

Emergency Contact Information

Driving / Insurance (for those in the household who drive)

Applicant #1 Driver Information

Applicant #2 Driver Information

Other Driver Information

Household Background Questions

Question A

Question B

Question C

Question D

Question E

Question F

Question G

Question H

Question I

Question J

Certification & Signatures