HOST HOME PROVIDER APPLICATION

Applicant's Name:  Last      First     Middle 

Street Address:   Phone:

City:    Zip Code:

County:

Email: 

Other Household Members: Names - Ages - Relationship

Name   Age    Relationship

Name   Age    Relationship

Name   Age    Relationship

Name   Age    Relationship

Name   Age    Relationship

Name   Age    Relationship

Do any of these people pay you to live in your home? Yes  No


HOUSING AND ACCESSIBILITY INFORMATION

Housing type:  House   Apartment   Condo    Mobile Home   Other,  Describe

Do you:   Own    Rent     Other, Describe

Number of Bedrooms: Bathrooms:

Would you permit adaptations for any necessary handicap devices?  

Is your home currently wheelchair accessible?        

Are the front and back entrances ramped?     

Are there handrails and grab bars installed?    

Is the bedroom on a main floor?    

Would the resident have wheelchair access to all common areas of the home, living room, kitchen, etc?  

Is the bathroom accessible with grab bars, raised toilet seat, wheel-in shower, etc?      

Please provide any additional information which describes the degree to which
your home is wheelchair accessible inside and out:

Pets (number and type)

Would you need to change your current residence before starting a Host Home? Yes  No

How much notice would you need to move, if necessary?


VEHICLE AND DRIVING INFORMATION

Do you drive a 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?  State where issued   License Number  

Driver's License Expiration Date

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

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, ESL, 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."

  


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:

Please indicate any changes in family income you anticipate during the next year:


PRE-INTERVIEW QUESTIONNAIRE

1. Have you been employed by Imagine! previously?  Yes  No

If yes, give date & position:

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

3. Does anyone living in your home currently have a communicable disease? Yes  No  If yes, please explain: (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? Yes  No       If yes, name of person & related offense:

5. 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? Yes  No

If yes, please explain:

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? Yes  No

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:

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

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

14. 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.

Applicant's Name:       Date: