Shared Living Provider Information...

Date:

Last Name:   First Name: Middle Initial:

Address: Apt. #:

City: State: Zip Code:

Telephone: (day) - (evening): -

Are you legally eligible for employment in the U.S.A.? Yes  No

Are you under the age of 21? Yes    No

Do you have a valid driver's license?  Yes    No

Have you ever been employed by HMEA?  Yes    No  If yes, when:

Has any member of your household ever been employed by HMEA?  Yes    No  If yes, when:

Have you previously applied for a position with us? Yes    No  If yes, when:

Have you ever been a Shared Living Provider? Yes    No  If yes, when and with what agency:

Work Experience...

Please list below your previous three employers, beginning with the most recent. Please use the space provided for comments to explain any gaps in employment,

or if you have less than five years of work experience.

Company Name:

Address:

Position held:

From: / To: /

Reason for leaving:

Company Name:

Address:

Position held:

From: / To: /

Reason for leaving:

Company Name:

Address:

Position held:

From: / To: /

Reason for leaving:

Educational History...

Please provide the following information:

Do you have a high school diploma or equivalency? Yes    No 
(please specify):

High School Attended:

Address: 

Year Graduated:

College Attended:

Year Graduated:

Degree Attained:

College Attended:

Year Graduated:

Degree Attained:

References...

List three references that we may contact (2 personal and 1 professional):

Name:

Relationship:

Address:

City: State: Zip Code:

Telephone: -

Name:

Relationship:

Address:

City: State: Zip Code:

Telephone: -

Name:

Relationship:

Address:

City: State: Zip Code:

Telephone: -

ADDITIONAL QUESTIONS...

1. Please list all the people living with you, beginning with the children:

2. Have you had any personal experience with people with disabilities?  Yes  No  

    Please explain:

3. What is your motivation for becoming a Shared Living Provider?

4.  Please tell us the three most important values in your life, then comment on each one:

    1.

    2.

    3.

5. Do you have access to a car or other transportation 24 hours/day?   Yes  No  

    Please describe:

    Is it registered?   Yes  No  

    Is it insured?    Yes  No  

6. How long have you lived in your current home: months  years

    Would you be willing to relocate if it increased the likelihood of becoming a Shared Living Provider?  Yes  No  

7. Do you own pets?    Yes  No

    If yes, please described your pets (i.e. type of pet and name):

8. We are looking for a minimum of a 3 year commitment. How long of a commitment are you willing to make should you be chosen as a Provider?

9. Have you ever been investigated for abuse and/or neglect of an individual with a developmental disability?  Yes  No  

    If yes, what was the outcome of the investigation? Please comment:

10. In this section, please add any comments about yourself and/or your family that you feel are important for us to consider when reviewing your information:

I hereby give HMEA the right to make a thorough investigation of my past employment, education and activities and I release from all liability all persons, companies and corporations supply such information. I indemnify HMEA again any liability, which might result from making such investigation. I understand that any false answer or statement or implication made by me in this application or other required documents shall be considered sufficient cause for denial of approval or termination of contract.

Additionally, I understand that nothing contained in this Shared Living Provider Information form or in the granting of an interview is intended to create a contract between HMEA and myself for either a Shared Living arrangement or for the providing of any benefit. No promises regarding Shared Living have been made to me and I understand that no such promise or guarantee is binding upon HMEA unless made in writing. If a Shared Living Provider relationship is established, I understand that I have the right to terminate the relationship at any time and that HMEA retains a similar right.

CORI

As part of our process, candidates to be a Shared Living Provider, as well as all household members over the age of 18, will be required to undergo a Criminal Offender Record Inquiry (CORI). Any information obtained will be kept confidential and will not necessarily disqualify an applicant.

If you do not understand any information given or questions asked in this application, please ask for an explanation.

By typing my name below I certify this to be my true identity. I understand that if granted an interview I will be required to verify my identity using photo identification. At that time, I agree to provide a handwritten signature in the space below.

Signature:   Date: