AcAAsA Academy

Confirm You’re Ready to Enroll Your Caregiver

Most providers can complete this in under 2 minutes.

AFH Eligibility*

Licensed AFH provider

At least one Medicaid OCCUPIED bed

AFHTN Orientation completed (past year)

ProviderOne list ready

Caregiver Eligibility and Documentation*

Caregiver applicant has worked at least 8 hours at this home (these 8 hours must be within the time frame from the date of hire)

Government-issued ID ready

Social security card ready

Eligible to work in the U.S. (I-9)

Passed background check + fingerprinting

Signed job offer ready

AFH Provider Information

AFH business name*

AFH license number*

Contact person name*

Phone number*

Email address*

AFH address*

Caregiver Applicant Information

Full name (as on ID)*

Phone number*

Email address*

Email address Confirm email address

Date of birth*

Mailing address*

Caregiver Applicant Information

Government-issued ID number*

Upload ID image*

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

Supported formats: JPG, PNG, PDF (Max 5MB)

SSN*

Upload SSN Card*

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

Supported formats: JPG, PNG, PDF (Max 5MB)

Caregiver Applicant Information

Hire/intend to hire date*

Gender*

Race/ethnicity*

Highest level of education completed*

Disability*

Military Veteran*

Caregiver Eligibility Attestation

Caregiver Eligibility Attestation check*

I attest that the caregiver has provided documentation meeting I-9 employment eligibility requirements to work in the United States

I attest that the caregiver has successfully completed a background check and fingerprinting and is eligible to work in an Adult Family Home in Washington State.

By signing below, you confirm that all information provided in this application is accurate and complete, and that you have read and agree to the Training Enrollment Agreement.

Signature (type your full name)*

Your typed name serves as your legal signature.

Date*

Training Information

Referral Source**

Can the Caregiver take the training online?*

What date can the Caregiver start training?*

Does the Caregiver have previous healthcare experience?*

If yes, please describe experience.*

Does the Caregiver have any other certificates?

If yes, please list below.

Select Training

Select training language*

Select training school region*

Does the caregiver need a caregiver license*

Yes

No

Training Course*

Select training company*

Specialty Courses (optional)

Section Break

Training Course

Select training company

Add another specialty course

AFH Provider Training Agreement

ADULT FAMILY HOME WORKFORCE ACADEMY
TRAINING ENROLLMENT AGREEMENT

This Training Enrollment Agreement ("Agreement") is entered into as of the date indicated below between the Adult Family Home Workforce Academy ("Academy") and the undersigned Adult Family Home Provider ("Provider").

1. PURPOSE

The Academy provides state-approved training programs to prepare caregivers for employment in Adult Family Homes. The Provider agrees to enroll eligible caregiver(s) in the training program(s) selected in this application.

2. PROVIDER RESPONSIBILITIES

2.1 Ensure all information provided in this application is accurate and complete.

2.2 Verify that the caregiver meets all eligibility requirements for funded training.

2.3 Ensure the caregiver attends all required training sessions and completes coursework.

2.4 Provide employment to the caregiver upon successful completion of training for a minimum period as required by funding guidelines.

2.5 Maintain compliance with all Washington State DSHS regulations for Adult Family Homes.

3. ACADEMY RESPONSIBILITIES

3.1 Provide quality training in accordance with Washington State Department of Health requirements.

3.2 Maintain qualified instructors and appropriate training facilities.

3.3 Process training certifications upon successful completion.

3.4 Maintain confidentiality of trainee records in accordance with applicable laws.

4. FUNDING AND PAYMENT

Training costs may be funded through state workforce development programs. If the caregiver fails to complete training or does not meet employment commitments, the Provider may be responsible for training costs as specified in funding guidelines.

5. ATTENDANCE AND COMPLETION

Caregivers must attend at least 90% of scheduled training hours and pass all required assessments to receive certification. Any absences must be communicated to the training provider in advance.

6. TERMINATION

Either party may terminate this agreement with written notice. The Provider understands that withdrawal from training may affect future funding eligibility and may result in financial obligations.

7. CONFIDENTIALITY AND DATA USE

The Academy will maintain confidentiality of all personal information in accordance with HIPAA and Washington State privacy laws. Information may be shared with funding agencies and regulatory bodies as required for program administration and compliance.

8. COMPLIANCE

Both parties agree to comply with all applicable federal, state, and local laws, including but not limited to those governing employment, discrimination, data privacy, and healthcare training.

9. ENTIRE AGREEMENT

This Agreement constitutes the entire understanding between the parties and supersedes all prior agreements. Any modifications must be made in writing and signed by both parties.

By signing in Step 5, the Provider acknowledges that they have read, understood, and agree to all terms and conditions of this Training Enrollment Agreement.

Contract Signature

By signing below, you confirm that all information provided in this application is accurate and complete, and that you have read and agree to the Training Enrollment Agreement.

Signature (type your full name)*

Your typed name serves as your legal signature.

Date*

Review your application: Please ensure all information is accurate before submitting. You will receive a confirmation email once your application has been processed.

AFH Training Application

Confirm You’re Ready to Enroll Your Caregiver

AFH Provider Information

Caregiver Applicant Information

Caregiver Applicant Information

Caregiver Applicant Information

Caregiver Eligibility Attestation

Training Information

Select Training

Specialty Courses (optional)

Section Break

AFH Provider Training Agreement

Contract Signature