Host Home Provider Application Name First Last Phone (Home):Phone (Work):Phone (Cell):Email(Required) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you reside in El Paso County? Yes No If Yes, How Long?Driver's License # Name of other Individuals currently living in your home: (if individual in services do not list name or DOB)NameDate of BirthRelationship Add RemoveClick the + sign at the end of the row to add additional lines.A BACKGROUND CHECK IS REQUIRED FOR ALL ADULTS LIVING WITHIN A HOST HOMEHave you ever worked as a Host Home Provider before? Yes No If Yes, give dates and position: Are you currently licensed to provide foster/day care in your home? Yes No Have you or anyone in your household ever been a host home provider? Yes No Dates services were provided? MM slash DD slash YYYY Name of Provider: Name of Agency: Please provide your daily schedule, including hours worked and on-going commitments ( include classes, clubs,meetings,etc)MondayTuesdayWednesdayThursdayFriday Add RemoveClick the + sign at the end of the row to add additional linesWhat is your primary language spoken in the home? Indicate any other language you speak fluently. Are you profficient in sign language? Yes No Education & TrainingWhat is the Highest Level of education you have completed?High SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOtherPrefer Not to AnswerList any special certifications in related fields.CertificationDate Add RemoveClick the + sign at the end of the row to add additional certificationsList 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.DateClassPresenter Add RemoveClick the + sign at the end of the row to add additional lines.
