Other Household Members:
Have you been employed by FGI previously?
Have you ever provided Host Home or Foster Care Services?
If yes, what Service Agency or County:
Does anyone currently living in your home have a communicable disease?
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?
If yes, name of person and related offense:
Have any individuals ever been removed from your home due to MANE allegations?
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?
If yes, please provide details:
Are you or any member of your houshold a smoker?
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?
I could best support a person with the following care needs:(Choose all that apply)
Is there a particular individual for whom you are interested in providing services? If yes, please name: