Share Living Arrangement Application

SLA Provider Application

Avatar is a certified placement agency for Shared Living Programs throughout Rhode Island. If you are interested in applying to be a SLA provider, please fill out the form below.
Personal Information:
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Driver's License Number
If applicable
Do you have a valid driver's license?*

YesNo
Do you have the minimum vehicle insurance required by the State of Rhode Island?*

YesNo
How did you hear about Shared Living Arrangements?
Your Residence:
What type of residence do you live in?*

HouseApartmentMobile/Modular homeCondoOther
Do you rent or own?*

RentOwn
Do you have home owner's or renter's insurance?*

YesNo
If renting, do you have landlord approval to have a non-related individual move into your home?

YesNoI haven't asked yet
How long have you lived at your current address?*
What is the total number of rooms in your home?*
What is the total number of bedrooms in your home?*
What is the total number of bathrooms in your home?*
Education
Name of High School*
Location of High School*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date attended (started)*

MonthDayYear
Date
Date attended (ended)*

MonthDayYear
Date
Character References:

At least ONE character reference must not be a relative.
Reference #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #2*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #3*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment Status:
Are you currently employed?*

YesNo
What is your annual income?
Employment History:

Starting with your present or most recent employer.
Employer #1*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Supervisor*
Supervisor's Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Your Job Title/Description of Duties*
Employment Date (Start)*

MonthDayYear
Date
Employment Date (End)*

MonthDayYear
Date
Why did you leave?*
Employer #2
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Supervisor
Supervisor's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Your Job Title/Description of Duties
Employment Date (Start)

MonthDayYear
Date
Employment Date (End)

MonthDayYear
Date
Why did you leave?
Employer #3
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Supervisor
Supervisor's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Your Job Title/Description of Duties
Employment Date (Start)

MonthDayYear
Date
Employment Date (End)

MonthDayYear
Date
Why did you leave?
Personal
Please explain, in your own words, your reasons for wanting to share a home with a person with intellectual/developmental disabilities. What changes do you anticipate that this will make in your lifestyle and that of your family? Please describe what you see as the benefits as well as the disadvantages to such an undertaking?*
What personal qualities and characteristics do you possess that you believe will assist you to be effective as a Shared Living Provider?*
Please describe your experiences with individuals with IDD. This may include volunteer experiences, providing respite care, etc.*
Please describe any skills, qualifications, and training acquired from employment and/or other experiences that may assist you to be effective as a Shared Living Provider.*
What do you foresee to be the greatest challenges involved in welcoming an adult with disabilities into your household?*
What are your interests and personal hobbies?*
Is there any additional information about you and/or your family that you would like us to consider?
Membership of Household

Please list all who reside in your home (spouse/partner, children, roommates, other).
Resident #1*

First NameLast Name
Relationship*
Is this person older than 18? If so, they will also need a BCI.*

YesNo
Resident #2*

First NameLast Name
Relationship*
Is this person older than 18? If so, they will also need a BCI.*

YesNo
Resident #3*

First NameLast Name
Relationship*
Is this person older than 18? If so, they will also need a BCI.*

YesNo
Please list any additional residents including their relationship to you and if they are over the age of 18 years.
Do you have any frequent visitors/overnight guests?

YesNo
Personal History

Please answer the following questions in detail. All of this information will be discussed on an individual basis during a personal interview.
Physician's Name - your physician will be asked to complete a simple form providing their opinion on your ability to become a Shared Living Provider based on your health.*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any pets?*

YesNo
Have you or any member of your household ever been convicted of abuse or neglect?*

YesNo
Do you have any friends or relatives who are Shared Living Providers?*

YesNo
Have you ever been, or applied to be, a Shared Living Provider or Foster Care Provider before?*

YesNo
Would you be willing to provide respite care (temporary short term living arrangements)?*

YesNo
Send Application:

I authorize full review and verification of the information contained in this application. I release from liability any person giving or receiving information about my application. I understand that any misrepresentation of deliberate omission on this document may be justification for refusal or consideration or termination of contract. I also understand that Avatar Residential Inc. will conduct the following clearance checks: National Criminal (BCI), Division of Motor Vehicle, Credit History, Character References, Professional References, and Physician's Reference.
Date*

MonthDayYear
Date
Signature*
Should be Empty:

SLA Provider Application

Personal Information:

Your Residence:

Education

Character References:

Employment Status:

Employment History:

Personal

Membership of Household

Personal History

Send Application: