FamilyEnroll

Welcome to the Enrollment Form for the CARE Program!

This form is for families to enroll in the CARE Program to receive Homemaker Personal Care (HPC) services.

HPC Family Enrollment

Step 1 of 3

This first section is information needed from the individual who will be receiving services.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
County of Residence

Now we need information about the county board & waiver
SSA's Name
First Last
SSA's Email Address
SSA's Phone
Are there other services being provided for this individual?
You can type YES, NO, or UNSURE. These services can include other means of shared living, HPC, Non-Medical Transportation, and/or respite.
Approximately how many days a week are you wishing to provide Shared Living?

This final section is for information about you.
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
Phone
Do you have any relatives that are currently employed by Goodwill?
Have you ever been employed by Goodwill?
If so, when & where?
Electronic Signature*