Membership Signup

Adult Family Home Council

AFH Name(Required)

The Adult Family Home Name

Licensee Name(Required)

Full name of Licensee

DSHS License #(Required)

AFH Address(Required)

Street Address Address Line 2 City ZIP Code

Referred by

My mailing address is different than the AFH address.

Yes

Mailing Address

Street Address Address Line 2 City ZIP Code

Phone

Fax

Cell

Website

Use ProviderOne for subscription dues(Required)

If you prefer you can use the ProviderOne system to deduct your monthly membership dues.

Yes

Email(Required)

ProviderOne ID(Required)

Enter your 9 digit ProviderOne number

Choose your credentials to set up your Adult Family Home Council user account

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Username(Required)

Password(Required)

Enter Password Confirm Password

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