Host Home Provider Application

Last Name First Name Middle Name

Address

City Zip County

Phone Email

Other Household Members:

Name Age Relationship

Do any of these people pay you to live in your home? Yes No

Housing type House Apartment Condo Mobile Home Other, Describe

Do You: Own Rent Other, Describe

Number of Bedrooms:

Number of Bathrooms:

Does your home have a wheelchair ramp entrance? Yes No

Are there handrails and grab bars installed? Yes No

Is the bedroom on the main floor? Yes No

Would the resident have 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:

Do you drive a vehicle? Yes No

If yes, Type? Make: Model: Year:

How many passengers can ride in this vehicle with seatbelts?

Tell us about your driver's license. State where issued: License Number: Expiration Date:

Are you willing to provide Home-to-Program transportation? Yes No

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

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:

Other special training, e.g., skilled trade, LPN, college dgrees & areas of study:

Employer#1

Name of Employer:

Address:

Supervisor: Phone:

Employed From: Employed To:

Job Title:

Job Duties:

Reason for Leaving:

Employer#2

Name of Employer:

Address:

Supervisor: Phone:

Employed From: Employed To:

Job Title:

Job Duties:

Reason for Leaving:

Employer#3

Name of Employer:

Address:

Supervisor: Phone:

Employed From: Employed To:

Job Title:

Job Duties:

Reason for Leaving:

Please give the following information for three personal references. Do not use relatives or employers listed above.

Reference #1

Name: Street:

City: State: Zip:

Phone: Relationship:

Reference #2

Name: Street:

City: State: Zip:

Phone: Relationship:

Reference #3

Name: Street:

City: State: Zip:

Phone: Relationship:

The above information is complete and accurate to the best of my knowledge. I understand that if FGI chooses to contract with me, any misstatement or omission of fact on this application shall be considered cause for termination of the contract.

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 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.

I Agree I Disagree

Have you been employed by FGI previously? Yes No

Have you ever provided Host Home or Foster Care Services? Yes No

If yes, what Service Agency or County:

Does anyone currently living in your home have a communicable disease? Yes No

If yes, please explain: (Applicants selected will be required to provide a physician's statement.)

Have you or any member of your household been convicted of a felony, child abuse, or an unlawful sexual offense? Yes No

If yes, name of person and related offense:

Have any individuals ever been removed from your home due to MANE allegations? Yes No

If yes, please provide details:

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 houshold been arrested for violations of the law other than minor traffic violations? Yes No

If yes, please provide details:

Are you or any member of your houshold a smoker? Yes No

Why are you interested in providing a host home?

What qualities do you feel a Host Home should provide for an adult with developmental disabilities?

Do you have any experience or exposure to individuals with intellectual/developmental disabilities? If so, please describe.

FGI's Host Home contracts may be renewable, and are developed 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 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:

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 cancelation of my Host Home agreement.

Applicant's Name: