Apply for Host Home Provider

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Host Home Provider
ID:HH 0417
Department:Operations
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Opt-In Confirmation
I authorize recruiters from Empowering Abilities to send text messages from 8882706983 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
Attachments
Resume:
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Cover Letter:
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Host Home Provider Application
* Address
* Address 2
* City/Town
* State/Province
* ZIP/Postal Code
* Email Address
* Phone Number
* Date of Birth
* Highest level of Education
* High School
College
Majors / Degree
* Employer
* Dates of Employment
* Job Title
* Address
* Phone
* Supervisor Name
* Reason For Leaving
* May We Contact This Person?
Yes
No
* Employer
* Dates of Employment
* Job Title
* Address
* Phone
* Supervisor Name
* Reason For Leaving
* May We Contact This Person?
Yes
No
Employer
Dates of Employment
Job Title
Address
Phone
Supervisor Name
Reason for Leaving
May We Contact This Person?
Yes
No
Employer
Dates of Employment
Job Title
Address
Phone
Supervisor Name
Reason for Leaving
May We Contact This Person?
Yes
No
* Reference Name
* Relationship to Reference
* Reference Phone Number
* Reference Email
* Reference Name
* Relationship to Reference
* Reference Phone Number
* Reference Email
* Are you a citizen of the United States?
Yes
No
If not a citizen, are you able to submit proof of your ability to work in the United States legally?
Yes
No
* Are you currently or have you ever contracted as a Home Host Provider?
Yes
No
If yes, please provide the following information: Placement, agency, age, gender, length of stay, and reason for move.
* Have you or any member of your family ever been arrested for violations of any law other than minor traffic violations? If yes, please explain:
* Have your or any member of your family/household ever been convicted of any crime, felony, child abuse, or an unlawful sexual offense? If yes, please explain: give names, dates, and final outcome.
* Why are you interested in providing Host Home services?
* List skills you possess that would make you a successful Host Home Provider:
* List other obligations you plan to continue during your contract (job, family commitments, etc.):
* Is there anything else you would like to tell us about yourself or your circumstances?
* List any specialized training, apprenticeship, skills and extra-curricular activities:
* Are you willing to consider supporting 24-hour supervision/care?
Yes
No
* Are you willing to consider supporting poor/nonexistent self-help skills (24-hour care needs)?
Yes
No
* Are you willing to consider supporting mild to moderate medical needs?
Yes
No
* Are you willing to consider supporting severe medical needs?
Yes
No
* Are you willing to consider supporting seizure disorders?
Yes
No
* Are you willing to consider supporting non-ambulatory/wheelchair (your home must be able to be modified to become wheelchair accessible: exterior door with ramp installed, wide doorways, grab bars, etc.)?
Yes
No
* Are you willing to consider supporting partial ambulatory/walkers?
Yes
No
* Are you willing to consider supporting mild to moderate behavioral challenges?
Yes
No
* Are you willing to consider supporting severe behavioral challenges?
Yes
No
* Are you willing to consider supporting an individual labeled as a sex-offender?
Yes
No
* Are you willing to consider supporting an individual with no access to children?
Yes
No
* Are you willing to consider supporting an individual that is blind?
Yes
No
* Are you willing to consider supporting an individual that is deaf?
Yes
No
* Are you willing to consider supporting an individual with severe communication challenges?
Yes
No
* Select the following gender/age/groups that you would be interested in serving:
Male
Female
Young adults 18-30 years old
Adults 30-50 years old
Older adults 50+ years old
* Which service are you able to provide?
Full-time Host Home
Respite
Respite in addition to a full-time Host Home
* Which of the following would you be able to accept from a consumer in your home?
Smoking
Pets
* Do you specialize in any specific populations?
Yes
No
* List of people living in your home. Please include individuals in services currently in your home. Please provide the following: Name, Relationship, Age, and Gender.
* List of frequent visitors to your home. Including part-time custody, grandchildren, nieces/nephews, or relatives/friends. Please provide the following: Name, Relationship, Age, and Gender.
* Do you work outside of the home?
Yes
No
* If yes, please provide place of employment, phone number, days, and hours.
* Do you have auto insurance?
Yes
No
* Vehicle Year/Make/Model
* Do you have Professional Liability Insurance?
Yes
No
* Are there smokers in the home?
Yes
No
* If yes, where do they smoke?
* List any pets in the home. Include type.
* Tell us about your home. House Style:
Ranch
Bi-level
Tri-level
Apartment
Other
* Do your own or rent?
Own
Rent
* If you rent, when is your lease up?
* Do you have homeowners insurance?
Yes
No
* Do you have enough bedrooms to ensure the individual doesn't share a room?
Yes
No
* How many bathrooms are in your home?
* Do you have a computer you are comfortable using?
Yes
No
* Describe your experience working with people with intellectual and/or developmental disabilities.
* Why are you interested in living with someone with intellectual and/or developmental disabilities?
* Describe your typical daily routine. (ex: 7am wake up, 9am kids to school, 6pm dinner, etc.)
* Is there anything you are uncomfortable doing?
* Do you have any limitations on transportation or availability? (ex. Day program, social events, personal activities, etc.)
* List your interests / hobbies
* I certify that answers herein are true and complete. I authorize investigation of all statements contained in this questionnaire as may be necessary in arriving at a contractual decision.
I understand that I will bear any costs of conducting an investigation into my criminal background, driving record, TB testing, screening for household members, and any other investigation deemed necessary by HDC. I will submit a check for the cost of initial screenings.
I may receive a copy of any reports for which I have been paid.
I certify that I am not presently debarred, suspended, or proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal Department or agency.
*
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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