Become A Host Home Provider

A host home provider is a caregiver/ independent contractor who welcomes a person with an intellectual and developmental disability into their own home to live in a safe, supportive, and community‑integrated environment.

Name

First Last

Phone (Home):

Phone (Work):

Phone (Cell):

Email(Required)

Address

Street Address Address Line 2 City State ZIP Code

Do you reside in El Paso County?

Yes

Driver's License Number and State

Name of other Individuals currently living in your home: (if individual in services do not list name or DOB)

Name

Date of Birth

Relationship

Click the + sign at the end of the row to add additional lines.

A BACKGROUND CHECK and CAPS IS REQUIRED FOR ALL ADULTS LIVING WITHIN A HOST HOME

Have you or anyone ever worked as an Independent Contractor before?

Yes

If yes, please describe your experience.

If yes, please provide the agency name, dates, and a brief description of your responsibilities.

What interests you about becoming a Host Home Provider?

What do you believe are the most important qualities of a successful Host Home Provider?

What experience do you have supporting individuals with communication, behavioral, medical, mobility, or personal-care needs?

Please provide your daily schedule, including hours worked and on-going commitments ( include classes, clubs,meetings,etc)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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Do you have reliable transportation?

Yes

Do you own or rent your home?

Yes

If renting, does your lease allow another adult to reside in the home? Yes / No / N/A

Yes

N/A

Do you have a private bedroom available for the individual receiving services?

Yes

Is your home a one level home without stairs? Yes / No

Is the home wheelchair accessible? Yes / No

Are there pets in the home? Yes / No

Click the + sign at the end of the row to add additional lines.

What is your primary language spoken in the home?

Indicate any other language you speak fluently.

Are you profficient in sign language?

Yes

Education & Training

What is the Highest Level of education you have completed?

List any special certifications in related fields.

Certification

Date

Click the + sign at the end of the row to add additional certifications

List any training you have attended, within the past year, related to serving persons with developmental disabilities ( e.g., assisting with medications, First Aid, CPR, legal rights, ETC.) Give dates attended and be prepared to produce proof for your file. Failure to provide required proof will result in having to repeat the class.

Date

Class

Presenter

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I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false, incomplete, or misleading information may result in denial of my application or termination of my participation as a Host Home Provider.(Required)

I certify the information provided is true and complete

I understand that becoming a Host Home Provider involves providing a safe, supportive, and person-centered home environment and supporting the individual in accordance with their Individualized Service Plan (ISP), applicable policies and procedures, and the requirements of Common Roots LLC and applicable state and federal regulations.(Required)

I Understand

I understand that all required background checks, CAPS checks, references, home assessments, interviews, and training requirements must be completed before I may provide services.(Required)

I Understand

I understand that submitting this application does not guarantee approval as a Host Home Provider. Final approval is determined by Common Roots LLC based on the applicant's qualifications, household circumstances, home environment, background screening, training, and ability to meet the needs of the individual being considered for placement.(Required)

I Understand

I authorize Common Roots LLC to verify the information provided in this application and to request information necessary to determine my suitability to provide Host Home services.(Required)

I agree

Applicant Name

Applicant Signature

Date

A Stronger Future Starts with Connection

Common Roots helps individuals build confidence, develop independence, and create meaningful relationships within their communities.

Become A Host Home Provider

A host home provider is a caregiver/ independent contractor who welcomes a person with an intellectual and developmental disability into their own home to live in a safe, supportive, and community‑integrated environment.

A BACKGROUND CHECK and CAPS IS REQUIRED FOR ALL ADULTS LIVING WITHIN A HOST HOME

Education & Training

A Stronger Future Starts with Connection

805 S. Tejon Street, Colorado Springs, CO 80903Phone: (719) 578-1227 | Fax: (719) 578-1322ntake@commonrootscos.com

805 S. Tejon Street,
Colorado Springs, CO 80903
Phone: (719) 578-1227 | Fax: (719) 578-1322
ntake@commonrootscos.com