Home » What We Do » Host Homes » Application Host Home 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 0% Entire form must be completed to be considered for a contract position. Please request any accommodations needed to complete form. Personal InformationName(Required) First Middle Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 No 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 No Have you previously been employed by Ablelight?(Required) Yes No Where?(Required) When?(Required) Have you ever worked under a different name?(Required) Yes No What name(s)?(Required) Have you ever been a Host Home Provider?(Required) Yes No With what agency?(Required) When?(Required) Education & CertificationsHigh SchoolNameLocation (City/State)Last Year CompletedDid you graduate?Course of StudyCollegeNameLocation (City/State)Last Year CompletedDid you graduate?Course of StudyOther EducationNameLocation (City/State)Last Year CompletedDid you graduate?Course of StudyOther certifications and experienceList 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 HistoryStarting 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 No When may we contact this employer?(Required) Additional CommentsCompany Name TelephoneCompany Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From (Month & Year) Employed Until (Month & Year) Starting Pay Ending Pay Job Title Name of Supervisor Describe Work PerformedMay we contact this employer? Yes No When may we contact this employer?(Required) Additional CommentsCompany Name TelephoneCompany Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From (Month & Year) Employed Until (Month & Year) Starting Pay Ending Pay Job Title Name of Supervisor Describe Work PerformedMay we contact this employer? Yes No When may we contact this employer?(Required) Additional CommentsAUTHORIZATION 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 ApplicationName(Required) First Middle Last Social Security No.(Required) 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Motor Vehicle RecordI 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)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDate of Birth(Required) MM slash DD slash YYYY Signature(Required) References & AuthorizationName of Applicant(Required) Position Applying For(Required) Former EmployerReference Information(Required)Supervisor NameJob TitlePosition StartPosition EndFull AddressPhone Number Add RemovePersonal ReferenceReference Information(Required)NameFull AddressPhone Number Add RemoveI 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) QuestionnaireWhat hours daily would you devote to monitoring and assisting this person?(Required)MondayTuesdayWedensdayThursdayFridaySaturdaySundayIf 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 Host Home or Family Caregiver program would be an endangerment to them or the person in services?(Required) Yes No Explain the condition (include alcoholism, substance abuse or mental illness)(Required) Do you or any members of your household smoke?(Required) Yes No Do you or any members of your household have a communicable disease?(Required) Yes No 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 No As a Host Home Provider, you would be responsible for providing or arranging transportation. What types of transportation would you provide to the consumer?(Required)YearMake & Model Add RemovePlease 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 Host Home or Family Caregiver program.(Required)HomeRenter's Insurance (if applicable)Auto PreferencesI 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 TV 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 InformationTell 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 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 No Would the person in services have a private bathroom?(Required) Yes No 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 ExtinguishersLocation Add RemoveIs the home wheelchair accessible for entry and exit?(Required) Yes No Is the home wheelchair accessible throughout the interior?(Required) Yes No Are bathrooms ADA compliant?(Required) Yes No Do you own any pets or maintain any animals on the property?(Required) Yes No Please Describe(Required) Have they ever shown any sign of aggression or unfriendliness?(Required) Yes No 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 SupportsHave you ever worked with individuals who were dually diagnosed (Intellectual/Developmental Disability and Mental Health)?(Required) Yes No 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 No Please Explain(Required) Are there any behaviors that you can deal with but will not allow in your home?(Required) Yes No Please Explain(Required) Physical SupportsHave 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) Δ
