Imagine! Host Home Provider Application

Applicant Information

Please use this application if you are interested in having an individual with an intellectual or developmental disability move into your home. If you would prefer to move into an existing Imagine! home with an IDD individual, please fill out our Companion Home Application instead.

First

Middle

Last

Gender

Street Address

City

Zip Code

County

Email

Phone

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?

Does your home have a wheelchair ramp entrance?

Yes

No

Are there handrails and grab bars installed?

Yes

No

Is the bedroom on a main floor?

Yes

No

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

Yes

No

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

Yes

No

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

Are you fluent in Spanish?

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.)

First Employer

Name of Employer

Address

Supervisor

Phone

Length of Employment From

To

Job Title

Job Duties

Reason for Leaving

Second Employer

#2 Name of Employer

Address

Supervisor

Phone

Length of Employment From

To

Job Title

Job Duties

Reason for Leaving

Third Employer

#3 Name of Employer

Address

Supervisor

Phone

Length of Employment From

To

Job Title

Job Duties

Reason for Leaving

Personal References

*We require 5 email references to be provided upon hire.

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

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

14. Of the behaviors listed below, select all that you would be willing to work with.

Physical Agression

Elopement

Theft

Verbal Agression

Property Destruction

Sexual Behaviors

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.

Applicant's Name

Date

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."

Agree

Disagree

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

Does your home have a wheelchair ramp entrance?

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?

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

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?

Educational Information

Employment Information (Please begin with most current.)

First Employer

Second Employer

Third Employer

Personal References

Income Information

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?

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)

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

Please Check the box below.