COMPANION HOME PROVIDER APPLICATION

Applicant's Name:  Last      First     Middle 

Street Address:

City:    Zip Code:

County:

Phone:

*Email: 

All of our homes can only accommodate a certain number of people. How many other people would be living with you
in the Companion Home? 

Would there be anyone living with you under the age of 18? Yes  No

What cities/towns would you prefer to live in?

How much notice would you need to move out of your current residence?

Pets (number and type):


VEHICLE AND DRIVING INFORMATION

Do you own or have access to a reliable vehicle? Yes No   
Vehicle type:  Make
  Model   Year

How many passengers can ride in this vehicle with seat belts?

Do you have a valid Driver's License?  Yes  No
State where issued
  License Number  
Driver's License Expiration Date

If selected for a Companion Home, Applicant must provide proof of current auto liability insurance with a minimum
personal injury coverage of $300,000.


PERSONAL INFORMATION

How would you describe your personality?:

List any hobbies and other personal interests:

What do you like to do in your spare time?:

Describe a typical weekend day for you:

How do you like to keep your living environment?:

What foods do you like to eat? How often do you cook your own food versus eating out?

What are your pet peeves?:


EDUCATIONAL INFORMATION

High School Graduate: Yes  No

GED or High School Equivalency? Yes  No

What experience do you have with sign language? List any courses taken or certifications obtained:

Also, list the types of sign you are experienced with (ASL, SEE, etc.), and how fluent you are with them:

Other specialized training, e.g., skilled trade, LPN, college degrees & areas of study:

List Professional, Trade, Business or Civic or Volunteer Activities & any offices held:


EMPLOYMENT INFORMATION (Please begin with most current.)

#1  Name of Employer:

Address:

Supervisor: Phone:

Length of Employment: to

Job Title:

Job Duties:

Reason for Leaving :
 
 

#2 Name of Employer:

Address:

Supervisor: Phone:

Length of Employment: to

Job Title:

Job Duties:

Reason for Leaving :
 

#3 Name of Employer:

Address:

Supervisor: Phone:

Length of Employment: to

Job Title:

Job Duties:

Reason for Leaving :
 


PERSONAL REFERENCES: Please give the following information for three personal
references. Do not use relatives or employers listed above.

#1 Name:     Street:

City:    State:   Zip:

Phone:     Relationship:                                                       

                                            

#2 Name:     Street:

City:    State:   Zip:

Phone:     Relationship:      

                                                

#3 Name:     Street:

City:    State:   Zip:

Phone:     Relationship:               

 


The above information I have provided is complete and accurate to the best of my knowledge.  I understand that if employed,
any misstatement or omission of fact on this application shall be considered cause for dismissal.

Failure to complete any section of this application may be cause for you not to be considered further.

"Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the employment application
is guilty of perjury in the second degree as defined in Section 18-8-503, C.R.S., and upon conviction thereof, shall be
punished accordingly."

  


PRE-INTERVIEW QUESTIONNAIRE

1. Have you been employed by Imagine! previously?  Yes  No
If yes, give date & position:

2. Have you ever provided Companion Home, Host Home or Foster Care Services?   Yes  No 
If yes, what Service Agency or County:

3. Have you been convicted of a felony, child abuse, or an unlawful sexual offense? Yes  No       
If yes, list the offense(s)

4. A background check will be conducted on applicants selected to be a Companion Home Provider.
A background check is also required for anyone 18 or older living in a Companion Home.

Have you been arrested for violations of the law other than minor traffic violations? Yes  No
If yes, please explain:

5.  Why are you interested in becoming a Companion Home Provider?

6. What qualities do you feel a Companion Home Provider should provide for a disabled adult?

7. List the skills and qualities that would make you a good Companion Home Provider:

8. Do you have any experience or exposure to the Developmental Disability community.  If so, please describe:

9. When would you be available to begin providing care?

10.  Being a Companion Home Provider typically involves being available during a variety of hours, both day and night.
Would you be able to provide the time and flexibility necessary to provide these services? Please describe:

11. Could you care for an adult who cannot be left unattended? Yes  No

12.  I could best support a person with the following care needs: (choose one, or all that apply)

Behavioral/Mental Health  -  Please provide details/comments:

Medically involved/Fragile  -  Please provide details/comments:

Independent with minimal supports  -  Please provide details/comments:

Older Adult/Senior Care  -  Please provide details/comments:

Sex Offender or Individual with Restrictions  -  Please provide details/comments:

13. Is there a particular individual for whom you are interested in providing services?
If yes, please name:

14. By entering my name below, I certify that I have truthfully answered the above questions to the best of my ability. I understand
that providing false or misleading information may result in the cancellation of my Companion Home Agreement Certification.

*Applicant's Name (Certify):       Date:

Please Check the box below.

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