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:1002
Department:Client Services
Resume
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Primary Phone:
* Email:
County:
How did you hear about CLA/Referred by?:
Preferred method of contact:
Hold Ctrl/Cmd to select multiple items
Attachments
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Host Home Provider Application
Please fill out this application completely
* Are you lawfully eligible to work in the United States?
Yes
No
* If you become a contractor with our agency, could you submit proof of your legal right to work in the United States?
Yes
No
* Have you contracted with or worked for Community Living Alternatives, Inc. before?
Yes
No
If yes, give dates
* Are you over the age of 21?
Yes
No
* Are you currently providing foster care or day care to anyone in your home?
Yes
No
* Have you ever been approved to provide host home services through any other agency?
Yes
No
If so, please list agencies:
* Are you currently providing host home services in your home for another agency?
Yes
No
If yes, please list agency:
* Which of the following are you interested in becoming?
Permanent Host Home Provider
Temporary Respite Provider
Both
* Are you currently employed?
Yes
No
* If selected to be a Host Home Provider will you continue employment?
Yes
No
* Number of hours currently working outside the home:
* Please provide your daily schedule,including hours worked and any on-going commitments (include classes, club meetings, etc.):
* Will you be relying on your monthly Host Home Provider payment to meet your current living expenses?
Yes
No
Residence Description
*
House
Apartment
Townhouse/Condo
Mobile home
Ranch
Single story
Two story
Tri-level
* Number of bedrooms
* Number of bathrooms
* Location of available bedroom(s):
Main floor
Upstairs
Basement
* Do you have a yard?
Yes
No
* Do you own or rent?
* Is your home wheelchair accessible? To what extent?
If no, would you be willing to make your home accessible?:
Yes
No
Preferences
CLA attempts to match interests and abilities of each Host Home Provider with those of the individual being served. Please respond to the following to assist us in this process:
* I prefer to work with the following age group:
under 21
21 to 30
31 to 50
over 50
No preference
* I prefer to work with the following gender:
Male
Female
No preference
* I feel I can work with an individual who:
smokes
uses a cane or walker
uses a wheelchair
doesn't use verbal communication
has a visual impairment
has a hearing impairment
has special diet needs
doesn't work or go to a day program
has special behavioral needs
has special medical needs
uses adult Depends
is sexually active
* I would like to provide a home for:
One person
Two persons
No preference
* What hours are you able to provide support services to a person(s) living in your home?
* Please specify any pets that share your home:
* Do you have any small children that frequently visit your home?
Other information to consider when placing someone in your home:
* What is your desired monthly compensation level?
* I would like to become a Licensed Foster Care Provider for children under the age of 18 years.
Permanent Provider
Temporary Respite Provider
No Preference
I do not want to become a Licensed Foster Care Provider
Activities
Please indicate your participation level for the following activities that you would like to do with an individual living in your home based on: 1-Never 2-Sometimes 3-Often 4-Very Often
* Movies:
1   2   3   4
* Theater:
1   2   3   4
* Concerts:
1   2   3   4
* Travel:
1   2   3   4
* TV:
1   2   3   4
* Meetings & Clubs:
1   2   3   4
* Library:
1   2   3   4
* Crafts:
1   2   3   4
* Shopping:
1   2   3   4
* Restaurants:
1   2   3   4
* Malls:
1   2   3   4
* Photography:
1   2   3   4
* Sports:
1   2   3   4
* Camping:
1   2   3   4
* Hiking:
1   2   3   4
* Fishing:
1   2   3   4
* Car Rides:
1   2   3   4
* Cards & Games:
1   2   3   4
* Swimming:
1   2   3   4
* Jogging/Walking:
1   2   3   4
* Sewing:
1   2   3   4
* Gardening:
1   2   3   4
* Bowling:
1   2   3   4
* Church:
1   2   3   4
* Music:
1   2   3   4
Other::
Household
* Names of other individuals currently living in your home including spouse, children, other dependents, etc. Please include their ages and relationship to you:
* Have you or any member of your household been arrested for violations of the law other than minor traffic violations?
Yes
No
If yes, please explain:
* Have you or any member of your household been convicted of a felony or misdemeanor?
Yes
No
If yes, describe:
* Are you or any member of your household currently on parole/probation?
Yes
No
If yes, please explain:
* Do you or any member of your household have any communicable disease(s)?
Yes
No
If yes, please explain:
* Is there someone living in your home 18 years of age or older that is intending to be you "back-up" support provider?
Yes
No
Education. Training, and Special Skills
* List any training you have attended, within the past year, related to serving person(s) with Intellectual/ Developmental Disabilities (e.g. Medication Administration/QMAP, Standard First Aid, CPR, Legal Rights, etc.) Give dates attended and be prepared to produce proof for your file. Failure to provide required proof will result in having to repeat the class.
* Do you have special certifications in related fields?
* What is the primary language spoken in your home?
* Indicate any other language you speak fluently:
* Are you proficient in sign language?
Yes
No
OTHER NOTICES
* If your file remains inactive (i.e. no proof of training turned in or all training has expired) then it will be destroyed after 6 months of inactivity. However, you are able to fill out another application and start the process again.
You must notify us of anything questionable that may show up on your background investigation. Failure to disclose arrest or conviction information prior to background investigation could greatly affect the possibility of contracting with our agency. This includes background information on other adults currently living in your home.

I have read and understood these notices:
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, gender, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.


Completion of this section is voluntary and will not affect your opportunity to contract with CLA. We appreciate your cooperation.
Gender:
Female
Male
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

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.
Submit
Cancel
ApplicantStack powered by Swipeclock