Host Home Providers Application

Please use this application if you are interested in having an individual with an intellectual or developmental disability move into your home. You can also download the form here and email it to us at thehostalternatives@yahoo.com

Applicant’s Name:

Gender

Street Address

City

Zip Code

County

Phone

Other Household Members

Name

Age

Relationship

Name

Age

Relationship

Please list additional household Members

Names - Ages - 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? Please Describe

Do you own or rent?

Own Rent

Other? Describe number of bedrooms and 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

Do you have pets? If so, how many and what kind?

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?

Yes No

Which state is your license issued?

What’s your Driver’s License Number?

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

Are you a High School Graduate?

Yes No

Do you have 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.

Please list any specialized training obtained, including skilled training, professional college degrees, and any other areas of study, if applicable.

List any volunteer activities in which you have participated.

Employment Information

(Please begin with most current)

First Employer

Name of Employer

Address

Supervisor

Phone Number

Length of Employment

Date Started

Date Ended

Job Title

Job Duties

Reason for Leaving

Second Employer

Name of Employer

Address

Supervisor

Phone Number

Length of Employment

Date Started

Date Ended

Job Title

Job Duties

Reason for Leaving

Third Employer

Name of Employer

Address

Supervisor

Phone Number

Length of Employment

Date Started

Date Ended

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

Have you been employed by the host alternatives previously?

Yes No

If yes, please provide date & position

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.)

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.

Why are you interested in providing a Host Home?

What qualities do you feel a Host Home should provide for a disabled adult?

Do you have any experience or exposure to the Developmental Disability community? If so, please describe.

The Host alternatives LLC 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?

When would you be available to begin providing care?

Do you have any obligations that would require you to be away regularly during the day or evening? Please describe.

Could you care for an adult who cannot be left unattended?

Yes No

I could best support a person with the following care needs

Choose one, or all that apply.

Behavioral/Mental Health Medically involved/Fragile Independent with minimal supports

Please provide details/comments

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

Physical Aggression Elopement Theft Verbal Agression Property Destruction Sexual Behaviors

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.

I agree

Applicant’s Name

Date