Family Model Provider Application
Please complete the following information in order to be considered to provide support services in your own residence to adults / seniors with or without a disability.
Contact information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Last four digits of SSN
*
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Additional information
Please answer the following questions.
Do you own or rent your home?
*
Please Select
Own
Rent
Do you have current homeowners or renters insurance?
*
Please Select
Yes
No
Do you have a valid Driver’s License?
*
Please Select
Yes
No
Do you have current vehicle insurance?
*
Please Select
Yes
No
Do you have reliable transportation?
*
Please Select
Yes
No
Have you ever been convicted of a felony?
*
Please Select
Yes
No
If yes, when and what?
*
Have you been convicted of a misdemeanor in the past 7 years?
*
Please Select
Yes
No
If yes, when and what?
*
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Home details
Please answer the following questions about your home details.
How many total beds / baths does your home have?
*
How many bedrooms / bathrooms are unused?
*
Are stairs required to enter the home?
*
Please Select
Yes
No
Are stairs required to reach the available bedroom?
*
Please Select
Yes
No
Is entry to the home handicap accessible?
*
Please Select
Yes
No
Are there any modifications made inside the home to accommodate a wheelchair (door ways, bathrooms, counter-height)? If so, describe.
*
Are there any pets in the home? If so, what?
*
Does anyone else live in the home with you? If so, what is their relation and gender?
*
Does anyone under 18 live in the home? If so, age and gender?
*
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Employment background
Do you currently have a job? If yes, what are your working hours?
*
Do you have prior experience supporting adults with intellectual or developmental disabilities? If so, where and when?
*
Do you have prior experience working with seniors with or without physical disabilities? If so, where and when?
*
What hours are you available to provide supervision if you supported a person in your home?
*
References
Please list 3 personal or professional references that would recommend you to be a Family Model Provider. Please list names and valid contact numbers.
Reference 1 - Name
*
Reference 1 - Phone number
*
Reference 2 - Name
*
Reference 2 - Phone number
*
Reference 3 - Name
*
Reference 3 - Phone number
*
Submit
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