Shared Living / Adult Foster Care Home Provider Application

Transcription

1 TODAY S DATE: Shared Living / Adult Foster Care Home Provider Application I. DEMOGRAPHICS Last Name First Middle Date of Birth: Address, City, State, Zip Age: Home Phone: Work Phone: Cell Phone: Address: Social Security #: - - Marital Status: Single Married yrs Divorced yrs Widowed yrs Separated yrs I prefer persons of ages: to. I would prefer Male Female Either Other Members of my household are: Name Age Relationship to Applicant What Languages are spoken in the home? Do you have any pets?. If so, how many and what are they? If no, do you mind pets? If the individual has a pet, can it be brought into your home?. Page 1 of 8

2 II. EDUCATION & EMPLOYMENT HISTORY A) Complete the highest degree of education you have earned: High School Diploma Associates Degree. Year Earned. Bachelors Degree. Year Earned. Master Degree. Year Earned. Doctorate Degree. Year Earned. B) Do you plan to continue your education? Yes No If yes, when, where & in What Subject: C) Do you belong to any Professional, Trade, or Service Organizations? Yes No (Please Specify) D) Have you ever applied for employment with us? Yes No E) Have you ever been employed by us? Yes No If yes, indicate position(s) held: F) Do you have a valid Driver s License? Yes No What State(s) Please list below your past 3 employers, starting with your most recent, regardless if you have submitted a resume. Choose a previous employer for Employment Verification and Reference to be completed on page 5. Dates Employer Position & Duties Reason for Employed Leaving Page 2 of 8

3 G) Please summarize skills and experience (paid and/or volunteer) that you possess relating to the field of intellectual and developmental disabilities. H) Please describe how your previous life and work experiences have prepared you to become a care provider. I) Have you ever been a care provider with another agency? If so, describe the length of time you were a care provider, what agency and that experience. Please provide the names of 3 people (1 Personal; 2 Professional) willing to give references: Name Relationship / Occupation Phone Number Agreement I authorize investigation of all statements on this application as is necessary in arriving at a contracting decision. I understand that misrepresentation or omission of facts called for is cause for immediate termination of any contractual agreement. Further, I consent to a CORI (Criminal Offender Record Information) investigation as part of the application process and authorize the CORI Coordinator to conduct further CORI investigations during the course of the contract. Signature of Applicant Date J) Are you willing to complete a Registry of Motor Vehicle Driving Record? Yes No Page 3 of 8

4 Reference Form Name of Applicant: Date: Person Completing Form (to be completed by Venture Community Services): 1.Professional Reference Info: (to be completed by Venture Community Services) Name: Title / Agency: Relationship to Applicant: How long what you know the applicant?: Dates of Employment: 1. What are the applicant s strengths and the areas to improve upon? 2. What experiences does the applicant have supporting individuals with developmental disabilities? 3. How does the applicant respond to feedback? 4.Has the applicant demonstrated the ability to communicate important information in an accurate and timely manner? 5. What role do you see the applicant taking as part as a team? (ex. Leader, follower, independent agent, peacemaker) 2. Professional Reference Info: (to be completed by Venture Community Services) Name: Title / Agency: Relationship to Applicant: How long what you know the applicant?: 1. What are the applicant s strengths and the areas to improve upon? 2. What experiences does the applicant have supporting individuals with developmental disabilities? 3. How does the applicant respond to feedback? 4.Has the applicant demonstrated the ability to communicate important information in an accurate and timely manner? 5. What role do you see the applicant taking as part as a team? (ex. Leader, follower, independent agent, peacemaker) 3. Personal Reference Info: (to be completed by Venture Community Services) Name: Relationship to Applicant: How long what you know the applicant?: 1. What are the applicant s strengths and the areas to improve upon? 2. What experiences does the applicant have supporting individuals with developmental disabilities? 3. How does the applicant respond to feedback? 4.Has the applicant demonstrated the ability to communicate important information in an accurate and timely manner? 5. What role do you see the applicant taking as part as a team? (ex. Leader, follower, independent agent, peacemaker) Page 4 of 8

5 III. DESCRIPTION OF HOME & PERSONAL PROFILE: Do you: Own Rent (your present home/apartment?) Number of Rooms:. Total Bedrooms. If house is multi-leveled, is there a bedroom on the ground floor? Yes No Is there a bathroom on the ground floor? Yes No Is your home handicapped accessible? Yes No Are you willing to relocate? Yes No If yes, list preferred communities: Please provide brief written answers to the following questions: 1. How do you think having an intellectually and/or developmentally disabled adult living in your home will affect or change your lifestyle? 2. What concerns do you have regarding becoming a care provider? 3. How do the significant others (family, friends ) in your life feel about you becoming a Shared Living Provider? 4. What interests or inspires you to become a care provider? Page 5 of 8

6 5. Describe your internal support system (family, friends, etc.) that help you process through difficult situations and events. 6. Describe what steps that you take to relieve stress when you feel overwhelmed. 7. What do you imagine will be the most difficult part in sharing your life, and home with another individual? 8. What do you hope to achieve by becoming a care provider? 9. What role does religion or spirituality play in your life? 10. How would you help an individual participate in a religion other than your own? 11. Please describe your home and neighborhood. Page 6 of 8

7 12. Describe your daily routine on a non-working day. 13. How would you help an individual maintain relationships with their family and friends? 14. What is your relationship with your neighbors? 15. What do you see as your role and responsibilities if you become a Shared Living Provider? 16. What do you see as the problems and barriers which developmentally disabled individuals must deal with? 17. How do you feel you could best assist a developmentally disabled person in dealing with these problems and barriers? 18. What do you think would be your role in assisting this individual to develop new areas of their life? Page 7 of 8

8 19. How do you see your role in problem solving and conflict resolution with this individual? 20. What could you offer to an individual living in your home with respect to social activity? 21. Describe how you would insure that the individual in your home would be integrated into the community. 22. Describe how you would assist the individual with maintaining and developing social relationships. 23. How long of a commitment would you be willing to make, should you be chosen as a home provider? years 24. Do you or your family have medical insurance coverage? Yes No 25. How many vehicles do you own? 26. Is / Are your vehicle (s) insured? Yes No IV. INTEREST / HOBBIES: 1) Describe what you do for fun. 2) Describe any groups, clubs or social organizations you hold a membership or are a participant. 3) Describe activities you engage in on a regular basis. Page 8 of 8