Host Home Provider Application

Applicant Information

Other Household Members Names - Ages - Relationship







Do any of these people pay you to live in your home?

Housing and Accessibility Information

Housing type

Do you

Vehicle and Driving Information

Do you drive a vehicle?

Vehicle type

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

Do you have a valid Driver's License?

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

Educational Information

Employment Information (Please begin with most current.)

First Employer

Second Employer

Third Employer

Personal References

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

First Reference

Second Reference

Third Reference

Income Information

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

Pre-interview Questionnaire

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

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 Host Home Agreement Certification.

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."

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