Host Home Provider Application

1 Personal

2 Education

3 Work History

4 References

5 About You

6 Job Fit

7 Home Profile

8 Statement

Host Home Provider Application

Personal Information Name: Address: Address 2: City/Town: State/Province: ZIP/Postal Code: Email Address: Phone Number: Date of Birth:

Education High School: College: Majors/Degree: Dates of Attendance:

Work History 1 Employer: Start Date: End Date: Job Title: Address: Phone: Supervisor Name: Reason for Leaving: May We Contact This Person?

Yes No

Work History 2 (Optional) Employer: Start Date: End Date: Job Title: Address: Phone: Supervisor Name: Reason for Leaving: May We Contact This Person?

Yes No

Work History 3 (Optional) Employer: Start Date: End Date: Job Title: Address: Phone: Supervisor Name: Reason for Leaving: May We Contact This Person?

Yes No

Reference 1 Name: Relationship: Phone: Email:

Reference 2 Name: Relationship: Phone: Email:

Reference 3 Name: Relationship: Phone: Email:

More About You Are you a citizen of the United States?

Yes No

If not a citizen, are you able to submit proof of your ability to work in the United States legally?

Yes No

Are you currently or have you ever contracted as a Host Home Provider for Adult Foster Care or Child Foster Care?

Yes No

If a consumer or child has lived in your home in the past, please provide: Placement Agency, Age, Gender, Length of Stay, and Reason for Move: Current Consumer(s) living in your home now: Placement Agency, Start Date, Age, and Gender. Please specify if there are none: Have you ever been investigated for Mistreatment, Abuse, Neglect, or Exploitation (MANE) allegations? If yes, please explain: Has a consumer ever been removed from your home? If yes, please explain: Have you or any member of your family ever been arrested for violations of any law other than minor traffic violations? If yes, please explain: Have you or any member of your family ever been convicted of any crime, felony, child abuse, or an unlawful sexual offense? If yes, please explain and provide names, dates, and the final outcome:

Job Specific Information Why are you interested in providing Host Home services? List skills you possess that would make you a successful Host Home Provider: List other obligations you plan to continue during your contract (job, family commitments, etc.): Host Home Provision is an around-the-clock endeavor. List your plans to get necessary respite, time off, and how you will be taking care of yourself: Is there anything else you would like to tell us about yourself or your circumstances? List any specialized training, apprenticeship, skills, and extra-curricular activities:

Home Profile Host Home Provider Name: Phone Number: Address: Date: If known, which person(s) are you interested in serving? Select the special needs that you would consider supporting:

24-hour supervision/care Poor/nonexistent self-help skills Mild to moderate medical needs Severe medical needs Seizure disorder Non-ambulatory/wheelchair Partial-ambulatory/walker Person labeled as sex-offender Severe behavioral challenges Blind Deaf Severe communication challenges Not allowed access to children

Select the gender/age groups that you would be interested in serving:

Male Female Young adults 18–30 years old Older adults 50+ years old

Which services are you able to provide?

Full-time consumer Respite Respite in addition to a full-time consumer Willing to serve more than two individuals Drive consumers to appointments Consumer have own bathroom (not a requirement) Home wheelchair accessible

Which of the following would you be able to accept from a consumer in your home?

Smoking Pets Neither Both

List of people living in your home. Include individuals in services: Name, Relationship, Age, & Gender. List of frequent visitors to your home (part-time custody, relatives, etc.): Name, Relationship, Age, & Gender. Do you work outside of the home?

Yes No

If yes, please provide place of employment, phone number, days, & hours: Do you have auto insurance?

Yes No

Vehicle Year/Make/Model: Are smokers in the home?

Yes No

If yes, where do they smoke? List any pets in the home (type): House Style:

Ranch Bi-level Tri-level Apartment Other

Do you:

Own Rent

If you rent, when is your lease up? Do you have homeowners insurance?

Yes No

Entrances into the home: List all entrances, steps, porch/patio/garage, and ramps installed: Inside home, on main level, how many stairs to walk up/down to their room?

0–5 steps 5–10 steps 10+ steps

Steps to Bathroom:

0–5 steps 5–10 steps 10+ steps

How many extra bedrooms are in your home? How many bathrooms? Do you have a computer you are comfortable using?

Yes No

Describe your experience working with people with intellectual and/or developmental disabilities: Why are you interested in living with someone with intellectual and/or developmental disabilities? Describe your typical daily routine: Describe your strengths and weaknesses: Is there anything you are uncomfortable doing? Do you have any limitations on transportation or availability? List your interests/hobbies: Additional comments:

Applicant Statement

I certify that answers herein are true and complete. I authorize investigation of all statements contained in this questionnaire as may be necessary in arriving at a contractual decision.

I understand that I will bear any costs of conducting an investigation into my criminal background, driving record, TB testing, screening for household members, and any other investigation deemed necessary by Peak. I will submit a check for the cost of initial screenings (other states or jurisdictions), which will be deducted from my first payment from Peak.

I may receive a copy of any reports for which I have been paid.

I certify that I am not presently debarred, suspended, or proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal Department or agency.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, TLC may terminate that contract at any time. It is further understood that any contract may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of Peak.

I understand that any false or misleading information given in this questionnaire or interview(s) may result in contract termination. I also understand that I am required to abide by all rules and regulations of Peak.

I have received, read, and understand the following documents: Host Home Provider Required Qualifications and Information & General Requirement.

I acknowledge and agree to the Applicant Statement above. Signature (Type Full Name): Date:

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