Home provider / Home Companions’ application form

This application is for those applicants who are interested in moving to an existing home managed by Host alternatives, in order to provide care for individuals with intellectual or developmental disabilities. You can also download the form here and email it to us at thehostalternatives@yahoo.com

Applicant’s Name:

Street Address:

City:

Zip Code:

County:

Phone:

Email: required

All of our homes can only accommodate a certain number of people. How many other people would be living with you in the Companion Home?

Would there be anyone living with you under the age of 18?

Yes No

What cities/towns would you prefer to live in?

How much notice would you need to move out of your current residence?

Pets (number and type)

VEHICLE AND DRIVING INFORMATION

Do you own or have access to a reliable vehicle?

Yes No

Vehicle type:

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

Do you have a valid Driver’s License?

Yes No

State where issued

License Number

Driver’s License Expiration Date

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

PERSONAL INFORMATION

How would you describe your personality?:

List any hobbies and other personal interests:

What do you like to do in your spare time?:

Describe a typical weekend day for you:

How do you like to keep your living environment?:

What foods do you like to eat? How often do you cook your own food versus eating out?

What are your pet peeves?:

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:

Do you know sign language? If so and how fluent you are with them:

Please list any other specialized training you have

EMPLOYMENT INFORMATION (Please begin with most current)

#1 - Name of Employer:

Address:

Supervisor:

Phone:

Length of Employment:

Job Title:

Job Duties:

Reason for Leaving:

#2 Name of Employer:

Address:

Supervisor

Phone:

Length of Employment:

Job Title:

Job Duties:

Reason for Leaving :

#3 Name of Employer:

Address:

Supervisor:

Phone:

Length of Employment:

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.” required

I agree I disagree