Family Model Provider Application for Children
Please complete the following information in order to be considered to provide support services in your own residence to children with 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.
Format: (000) 000-0000.
Email
*
example@example.com
Last four digits of SSN
*
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Why do you want to become a Family Model Provider?
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What ages and needs of children are you comfortable supporting?
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What discipline strategies do you use or have used in the past?
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What is your experience caring for children?
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Additional information
Please answer the following questions.
Do you own or rent your home?
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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?
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Please Select
Yes
No
If yes, when and what?
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Have you been convicted of a misdemeanor?
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Please Select
Yes
No
If yes, when and what?
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Have you worked with Child Protective Services?
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Have you had allegations of abuse or neglect?
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Do you have any experience working with the DIDDS population? (Developmental and Intellectual Disabilities)? If yes, please explain.
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Are you currently a stay-at-home parent?
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Are you willing to be a stay-at-home parent?
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Home details
Please answer the following questions about your home details.
How many total beds / baths does your home have?
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How many bedrooms / bathrooms are unused?
*
Are stairs required to enter the home?
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Please Select
Yes
No
Are stairs required to reach the available bedroom?
*
Please Select
Yes
No
Is entry to the home handicap accessible?
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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?
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Does anyone else live in the home with you? If so, what is their relation and gender?
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Does anyone under 18 live in the home? If so, age and gender?
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Has your home been inspected for safety compliance?
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If not, are you willing to comply with safety rules such as fire extinguishers on every level of the home, and weapons and medication properly stored per policy?
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Employment background
Do you currently have a job? If yes, what are your working hours?
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Do you have prior experience supporting children with intellectual or developmental disabilities? If so, where and when?
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What hours are you available to provide supervision, transportation, assistance with educational needs, attend court hearings and child and family team meetings as needed?
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Are you willing to attend required trainings and open to ongoing education and coaching?
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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
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Reference 2 - Name
*
Reference 2 - Phone number
*
Reference 3 - Name
*
Reference 3 - Phone number
*
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