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Shared Living Provider Application

Entire form must be completed to be considered for a contract position. Please request any accommodations needed to complete form.

Step 1 of 11 – Personal Information

Entire form must be completed to be considered for a contract position. Please request any accommodations needed to complete form.

Personal Information

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

How did you hear about this company?(Required)

Internet

Walk-in

Referral

Newspaper

Company Website

Radio

Other

By whom?(Required)

Please Specify(Required)

Are you at least 18 years of age?(Required)

Yes

If we establish a contract with you, can you show proof of legal authorization to conduct business and work in the United States? (Proof of citizenship or immigration will be required)(Required)

Yes

Have you previously been employed by Ablelight?(Required)

Yes

Where?(Required)

When?(Required)

Have you ever worked under a different name?(Required)

Yes

What name(s)?(Required)

Have you ever been a Shared Living (Host Home) Provider?(Required)

Yes

With what agency?(Required)

When?(Required)

Education & Certifications

High School

Name

Location (City/State)

Last Year Completed

Did you graduate?

Course of Study

College

Name

Location (City/State)

Last Year Completed

Did you graduate?

Course of Study

Other Education

Name

Location (City/State)

Last Year Completed

Did you graduate?

Course of Study

Other certifications and experience

List any other special activities, training, experience, or certifications that you believe would be of value to AbleLight and/or the Independently Contracted position you are seeking. For certifications/licenses, include type, number and expiration date.

Employment History

Starting with your current or most recent employer, account for the past seven years of employment history, including gaps in employment. Resumes are accepted but will not substitute for information requested on this application.

Company Name(Required)

Telephone(Required)

Company Address(Required)

Street Address Address Line 2 City State ZIP Code

Employed From (Month & Year)(Required)

Employed Until (Month & Year)(Required)

Starting Pay(Required)

Ending Pay(Required)

Job Title(Required)

Name of Supervisor(Required)

Describe Work Performed(Required)

May we contact this employer?(Required)

Yes

When may we contact this employer?(Required)

Additional Comments

Company Name

Telephone

Company Address

Street Address Address Line 2 City State ZIP Code

Employed From (Month & Year)

Employed Until (Month & Year)

Starting Pay

Ending Pay

Job Title

Name of Supervisor

Describe Work Performed

May we contact this employer?

Yes

When may we contact this employer?(Required)

Additional Comments

Company Name

Telephone

Company Address

Street Address Address Line 2 City State ZIP Code

Employed From (Month & Year)

Employed Until (Month & Year)

Starting Pay

Ending Pay

Job Title

Name of Supervisor

Describe Work Performed

May we contact this employer?

Yes

When may we contact this employer?(Required)

Additional Comments

AUTHORIZATION FOR RELEASE OF INFORMATION

I certify this information was completed by me and the entries contained are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts requested may be grounds for rejection of this application or termination of contract.

I authorize any inquiry which may provide background information concerning my character, general reputation, and past work performance. I hereby authorize AbleLight. to inquire, and authorize the request of each former employer, educational institution, persons, credit bureaus, governmental and law enforcement agencies to answer all questions which may be legally asked, and to release all information which may be legally sought. I hereby release all parties from any liability or responsibility for doing so.

If a contract is established with AbleLight, I agree to comply with all rules and regulations as set by my state or any other regulatory agency as applicable.

Name(Required)

Signature(Required)

Primary Application

Name(Required)

First Middle Last

Sex(Required)

Male

Female

Date of Birth(Required)

MM slash DD slash YYYY

Maiden Name

Other names (alias, married name, etc.)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Motor Vehicle Record

I consent to AbleLight’s obtaining information from relevant governmental agencies to verify my driving record annually throughout the time of my contract with AbleLight. I understand that any misrepresentation, falsification or omission of information is sufficient cause for refusal or of dismissal from my contract with AbleLight.

Name(Required)

First Middle Last

Driver's License Number(Required)

State of Issue(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Signature(Required)

References & Authorization

Name of Applicant(Required)

Position Applying For(Required)

Former Employer

Reference Information(Required)

Supervisor Name

Job Title

Position Start

Position End

Full Address

Phone Number

Personal Reference

Reference Information(Required)

Name

Full Address

Phone Number

I hereby authorize you verify and otherwise furnish AbleLight representative(s) with any employment information requested and any other information you may have concerning me. I hereby release you, your organization and AbleLight from any and all liability for any damage arising therefrom.

Printed Name(Required)

Signature(Required)

Questionnaire

What hours daily would you devote to monitoring and assisting this person?(Required)

Monday

Tuesday

Wedensday

Thursday

Friday

Saturday

Sunday

If you work, who would monitor and assist the person during your work hours?(Required)

What hobbies or interests do you have that you can share with someone in services?(Required)

What community activities or organizations are you involved in that you can offer participation to a person in services?(Required)

Does any member of your household have a disability to the extent that participation in the Shared Living (Host Home) or Family Caregiver program would be an endangerment to them or the person in services?(Required)

Yes

Explain the condition (include alcoholism, substance abuse or mental illness)(Required)

Do you or any members of your household smoke?(Required)

Yes

Do you or any members of your household have a communicable disease?(Required)

Yes

Explain(Required)

Would you and other members of your household agree to attend initial and ongoing orientation and training? (Required training includes CPR/First Aid, Medication Administration and other trainings)(Required)

Yes

As a Shared Living Provider, you would be responsible for providing or arranging transportation. What types of transportation would you provide to the consumer?(Required)

Year

Make & Model

Please list the companies and agents providing insurance coverage for your home or apartment rental insurance and automobile(s). A copy of these policies will be required at the time of acceptance into the Shared Living (Host Home) or Family Caregiver program.(Required)

Home

Renter's Insurance (if applicable)

Auto

Preferences

I Prefer to work with the following age group:(Required)

Under 21

21 to 30

31 to 50

Over 50

No preference

I Prefer to work with the following gender:(Required)

Male

Female

No preference

I would like to provide a home for:(Required)

One person

Two persons

No preference

Activities I (and/or my family) frequently participate in and would like to share:(Required)

Movies

Video Games

Travel

Clubs

Mall

Reading

Writing

Shopping

Restaurants

Sports

Photography

Church

Concerts

Theatre

Park

Games

Swimming

Jogging

Walking

Fishing

Camping

Hiking

Bowling

Crafts

Other

Please Specify(Required)

Environmental Information

Tell us more about your home(Required)

Home

Apartment

Townhome/Condo

Mobile Home

Type(Required)

Ranch

Single Story

Two Story

Tri-Level

Number of Bedrooms(Required)

Number of Bathrooms(Required)

Briefly describe your home(Required)

Make note of special features that would be of assistance to you in providing service in the Shared Living (Host Home) or Family Caregiver program. (List features such as spare rooms, additional bathrooms, fenced yard, local family/recreational areas, etc.).

Would the person in services have a private bedroom?(Required)

Yes

Would the person in services have a private bathroom?(Required)

Yes

On what level would the bedroom of the person in services be located?(Required)

Indicate the number and location of any fire extinguishers and smoke detectors in the home.(Required)

# of Smoke Detectors

# of Extinguishers

Location

Is the home wheelchair accessible for entry and exit?(Required)

Yes

Is the home wheelchair accessible throughout the interior?(Required)

Yes

Are bathrooms ADA compliant?(Required)

Yes

Do you own any pets or maintain any animals on the property?(Required)

Yes

Please Describe(Required)

Have they ever shown any sign of aggression or unfriendliness?(Required)

Yes

Please Describe(Required)

Briefly describe your neighborhood(Required)

Include distance to neighbors, stores, churches, recreational areas, public transportation, medical and emergency support services, types of homes, or anything of note that would benefit a person in services living in your home.

Behavioral Supports

Have you ever worked with individuals who were dually diagnosed (Intellectual/Developmental Disability and Mental Health)?(Required)

Yes

Have you ever worked with individuals who have displayed any of the following behaviors? (Check all that apply)

Stereotypical behaviors (rocking, hand-waiving, etc.)

Spitting

Pica

Verbal abuse (name-calling or other inappropriate verbalizations)

Self-abuse

Physical aggression towards others

Property destruction

Inappropriate sexual behaviors

Lying or stealing

Sun-staring, spinning, rocking, etc.

Teasing

Running away

Excessive or prolonged screaming

Biting

Are there any behaviors or physical disabilities that you feel you cannot tolerate at all?(Required)

Yes

Please Explain(Required)

Are there any behaviors that you can deal with but will not allow in your home?(Required)

Yes

Please Explain(Required)

Physical Supports

Have you ever worked with individuals who have had any of the following? (Check all that apply)

Non-ambulatory (uses wheelchair)

Assisted ambulation (uses walker, cane, braces, etc.)

Deaf

Blind

Does not use words to communicate

Prosthetic devices

Advanced medical needs (catheter, tube feeding, etc.)

Diabetic or other specialized dietary care needs

Seizures

List/explain the training that you have had in working with any of the above behavioral or physical supports.

I certify that all statements contained in my application are complete and correct. I understand that if I become a Host Home Provider or Family Caregiver, any false statements on this application shall be considered sufficient cause for termination of my contract.

Name(Required)

Signature(Required)

Shared Living Provider Application

Personal Information

Education & Certifications

Employment History

AUTHORIZATION FOR RELEASE OF INFORMATION

Primary Application

Motor Vehicle Record

References & Authorization

Former Employer

Personal Reference

Questionnaire

Preferences

Environmental Information

Behavioral Supports

Physical Supports

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