Adult Family Home Training Network Worker Sponsorship Pilot Program

Adult Family Home Sponsorship Application

Updated 2/25/22

The cost of the training and—for certain specified training—employee salary and benefits during the training, will be paid by The Long-Term Care Foundation from a portion of the training benefit negotiated for Adult Family Homes in the collective bargaining agreement with the State of Washington.

Information collected from this application will be part of a data analysis of the pilot program.

Adult Family Home

Address:

Is your adult family home approved to offer on-the-job training YesNo If Yes, what type of training:  

 Do you currently have a Medicaid contract?  YesNo 

How many Medicaid clients do you have?  

Do you have an applicant that you would like to sponsor through one or more qualifying training? YesNo 

Sponsored Applicant:

First Name: Last Name:  

Address: City:

State: Washington StateOther Zip Code: County:  

Telephone: Email:  

Date of Birth (MM/DD/YYYY): Hire Date/Intend to Hire Date:

Gender (Chose one): MaleFemaleNon-Binary Decline to answer Race (Check one): Hispanic White/CaucasianBlack/African AmericanAsianAmerican Indian or Alaska NativeHawaiian Native or Other Pacific IslanderMulti-racial Other Decline to Answer 

Disability: YesNoDecline to answer Military Veteran: YesNo 

Does the applicant have previous health care experience?: YesNo

If yes, please describe:  

Does the applicant currently hold any certifications? YesNo  If yes, please describe:  

Please check off what the applicant has completed below to work in Adult Family Home:

Background Check: YesNo Food Handlers: YesNo 

CPR/First Aid: YesNo TB test completed: YesNo 

Which of the trainings below are needed for applicant to become a long-term care worker?

Home Care Aide Training (75 hours) & Testing: YesNo        

Mental Health Specialty Training: YesNo Dementia Specialty Training: YesNo 

HCA Pre-Prometric Test Refresher: YesNo  

Nurse Delegation: YesNo  Nurse Delegation—Diabetes: YesNo  

Which of the following DSHS-approved training companies will you choose to provide the training you require?

Community Colleges of Spokane (offers Adult Education, AFH Administrator, HCA/CNA Bridge, HIV/AIDs, HCA, HCA Skills Refresher)

Cornerstone Healthcare Training Company, LLC (offers Dementia, HIV/AIDs, HCA, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

Long-Term Care Education Associates (offers Dementia, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

Headway Nursing Services (offers Dementia, HIV/AIDs, HCA, Mental Health, Nurse Delegation, Nurse Delegation Diabetes, Adult Education)

Northcare Training (offers Dementia, HCA, HCA/CNA Bridge, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

S&H Training Center, Inc. (offers Dementia, HCA, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

Washington Care Academy, LLC (offers Dementia, HCA, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

Other:

For those choosing CNA training, please visit https://www.doh.wa.gov/LicensesPermitsandCertificates/ NursingCommission/NursingEducation/ NursingAssistantCertified/ProgramList, pick your top three choices, and add them below

1)

2)

3)

Is the applicant able to take the training online?: YesNo  

How soon can the applicant begin the training?

Applicant's Highest Grade Completed: Less than high school graduationHigh School GraduateGEDSome Post H.S., no degree or certificateAssociate DegreeBachelor’s Degree or Above 

How did you hear about us? Referral The Long-Term Care Foundation Facebook PageThe Long-Term Care Foundation WebsiteOther 

Referral (who referred you):  

Adult Family Home Contact’s Signature:                                                                                                                               

Sponsored Applicant's Signature:                                                                                                                             

Program Eligibility Criteria (LTCF Use Only)
Medicaid Contract
Number of Medicaid clients
Has applicant completed HS/GED
Background Check
Is applicant committed to taking requested training
Training needed to complete requirements for certification
Applicant able to take requested training online
Applicant able/willing to use DSHS approved trainer
TB Test
CPR/First Aid
Food Handlers

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Document name: Adult Family Home Training Network Worker Sponsorship Pilot Program

Unique Document ID: f3aa6a2a3fd0613cfc6c964d5672486728bc0be8

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Timestamp	Audit
June 5, 2022 8:07 pm PDT	Adult Family Home Training Network Worker Sponsorship Pilot Program Uploaded by Faduma Mursal ( Director of Training Washington Care Academy) - washingtoncareacademy@gmail.com IP 73.225.24.78

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