Membership

National Association of Family Care Homes > Membership

Membership Application Form

Membership Application Form

Provider Membership applies to: Companies that own, manage, or operate an assisted living community.
Annual Membership cycle is January 1 – December 31.
Family Care Homes (6 or less licensed beds): # of Licensed Beds: ___ x $15.00 = Total of $ ______

Country

Provider Member licensed bed count

Member Company or Community Name

Contact Person/Title

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone

Email

About the Company

Parent Company Name

Contact Person/Title

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone

Email

Do you have a Special Care Unit?

Yes

No

Requirements for Accepting Medicaid?

Yes

No

Do you Accept Medicaid?

Yes

No

Do you Accept only private pay?

Yes

No

Please pay $75 after submitting the form using a link provided

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