dfs : : Pre-App Lifesharing

Thank you for your interest in Lifesharing. This PRE-APPLICATION is the first step in applying to be a provider with dFs. After it is received, a Supervisor will phone you to explain more about our agency and Lifesharing services.

AT THIS TIME WE ARE ABLE TO ACCEPT APPLICATIONS FROM PENNSYLVANIA RESIDENTS ONLY

Last Name

First Name

M.I.

Age

Street Address:

City:

Zip:

County:

Phone No:

School District:

Others in Household:	Relationship:	Age:

Employment/Income Information YOU:
You:
Occupation:
Employer:
Income if not employed:

Employment/Income Information YOUR SPOUSE:
You:
Occupation:
Employer:
Income if not employed:

Have you ever been a foster parent or provided Lifesharing to persons with developmental disabilites? If yes, with which agency?

Would you like to have a staff person contact you with more information and/or to receive an application? No Yes
If yes, please indicate the best time for someone to call when you might have 15-20 minutes to receive further information.

Best time: