The Host Home Provider usually cannot rely completely on the
contract provider payments to adequately meet the Provider's family needs. If
selected for a Host Home, my household will have income from
the following sources
1. Have you been employed by Imagine! previously?
2. Have you ever provided Host Home or Foster Care Services?
3. Does anyone living in your home currently have a communicable disease?
(Applicants selected will be required to furnish a physician's statement.)
4. Have you or has any member of your household been convicted of a felony, child abuse, or an
unlawful sexual offense?
A background check will be conducted on applicants selected for Host Home Provider. A background check is also required for anyone 18 or older
living in a Host Home.
Have you or has any
member of your household been arrested for violations of the law other than
minor traffic violations?
6. Why are you interested in providing a Host Home?
7. What qualities do you feel a Host Home should provide for a disabled adult?
8. Do you have any experience or exposure to the Developmental Disability community? If so, please describe
9. Imagine! Host Home contracts may be renewable, and are written to coincide with the agency's
budget year. How long do you anticipate being a Host Home Provider?
10. When would you
be available to begin providing care?
11. Do you have any
obligations that would require you to be away regularly during the day or
evening? Please describe
12. Could you care
for an adult who cannot be left unattended?
13.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
14. Of the behaviors listed below, select all that you would be willing to work with.
15. Is there a particular individual for whom you are interested in providing
services? If yes, please name