Community Options, Inc.

Prospective Host Home Provider Application

Please note that fields with an * are required, the application will not be submitted if these fields are not completed.

Date of Application * +

Legal Last Name *

First Name *

Middle

Street *

City *

State *

Zip *

Mailing Address (if different): *

Best Phone Number to reach you? 🛈

Please mark all that apply

Cell

Landline

Other?

Email Address

What is the best way to contact you? (Please mark all that apply)

Phone

Text

In order to provide host home services, you must be at least 21 years old. Do you meet this requirement? *

Yes

Do you have a HS diploma or GED? *

Yes

Do you live in a: *

House

Apartment

Other Other

Do you: *

Rent

Own

Please note ** (Individual served must have a bedroom which is a minimum of 80 sq. ft)

Number of Bedrooms? *

Number of Bathrooms? *

Is your home currently wheelchair accessible? 🛈

Yes

How long have you been at this address? (Mos/Yrs) *

Previous Address (if less than 5 years at current address:)

How long were you at this address? (Mos/Yrs)

Would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? *

Yes

Training

List any training/education relevant to the services you would provide.

	Training Topic	Location/Company Presenting	Date
1.	Training Topic	Location/Company Presenting	Date
2.	Training Topic	Location/Company Presenting	Date
3.	Training Topic	Location/Company Presenting	Date
4.	Training Topic	Location/Company Presenting	Date

What drew you to consider being a host home provider?

List any other information you would like us to know about you that would be relevant to providing host home services. Do not include information that indicates race, religion, gender, national origin, disability, or other protected status.

List the skills, qualities or characteristics that you have that could help you be successful in providing these services?

Do you plan to continue to work a regular job while providing Host Home services?

Yes

If yes, please explain your work schedule and how you will ensure service delivery throughout the day/week.

Community Options provides the required trainings for you. Would you be able to attend these trainings during the work week, during the day?

Yes

Transportation is another funding stream available to host home providers. Can you provide transportation on a routine basis?

Yes

List all the persons who will be living in your home (including yourself)

	Full Name	Age	Relationship
1.	Full Name	Age	Relationship
2.	Full Name	Age	Relationship
3.	Full Name	Age	Relationship
4.	Full Name	Age	Relationship
5.	Full Name	Age	Relationship

NOTE: EACH PERSON 18 YEARS OR OLDER INCLUDING YOU, MUST COMPLETE A CRIMINAL BACKGROUND CHECK, CAPS CHECK AND MVR IN ORDER TO BE CONSIDERED AS A HOST HOME PROVIDER. COI WILL CONDUCT BACKGROUND CHECKS WHICH ARE COVERED BY YOUR APPLICATION FEE.

Have you or anyone living with you been employed by or provided contract services for Community Options? *

Yes

If yes, please specify below:

	NAME	DATES (from/to)	POSITION OR CONTRACT SERVICE
1.	NAME	DATES (from/to)	POSITION OR CONTRACT SERVICE
2.	NAME	DATES (from/to)	POSITION OR CONTRACT SERVICE
3.	NAME	DATES (from/to)	POSITION OR CONTRACT SERVICE

Have you or anyone listed above provided Host Home or Foster Care services?

Yes

If yes, please list below:

	Name	Type of Service	Agency	Dates
1.	Name	Type of Service	Agency	Dates
2.	Name	Type of Service	Agency	Dates
3.	Name	Type of Service	Agency	Dates

Do you or those living with you smoke? (Smoking is a consideration in matching you with people who need host home services.)

Yes

For what length of time would you want to provide host home services?

Only temporarily (respite provider)

6 moths to a year

One year or longer

On what date would you be available to provide services, if approved? +

List three professional or business/employment related references.

	Name	Company	Day Phone	Email
1.	Name	Company	Day Phone	Email
2.	Name	Company	Day Phone	Email
3.	Name	Company	Day Phone	Email

List three personal (non-family) references.

	Name	Day Phone	Email	Relationship
1.	Name	Day Phone	Email	Relationship
2.	Name	Day Phone	Email	Relationship
3.	Name	Day Phone	Email	Relationship

Did an employee of Community Options refer you to be a host home provider?

Yes

If yes, who referred you? (Full name please)

APPLICANT STATEMENTS

I certify that the information provided on this form and on any resume or any other documents are true to the best of my knowledge.

I understand that I must be at least 21 years old to be a host home provider at Community Options.

In the event of a contract being extended to me, I understand that false or misleading information given on this form and all associated documents or interview(s) may result in immediate discontinuation of my contract.

Signature of Applicant (by signing this application you agree that your electrinic signature is the
legal equivalent of your manual signature)

Date Signed * 🛈 +

NOTE: INCOMPLETE APPLICAITONS WILL NOT BE CONSIDERED.

You can click here to return to our web site. Thank you. www.communityoptionsinc.org