HHP Application – Triuspa LLC

HOST HOME PROVIDER APPLICATION FORM

First Name *
Last Name *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email *
Phone *

Type of House
HouseApartmentCondoMobile HomeOther
Do you:
RentOwnOther
Number of Bedrooms
Number of Bathrooms
Is your house wheelchair accessible?
YesNo
Does your home have wheelchair ramp entrance?
YesNo
Are there handrails and grab bars installed?
YesNo
Is the bedroom on the main floor?
YesNo
Would the resident have access to all common areas of the home; living room, kitchen, etc?
YesNo
Is the bathroom accessible with grab bars, raised toilet seat, wheel-in shower, etc?
YesNo
Please provide any additional information which describes the degree to which your home is (1)wheelchair accessible and (2) would be suitable to better serve clients
Pets (Number and Type):
How much notice would you need to move, if necessary:

Do you drive a vehicle?
YesNo
How many passengers can ride in this vehicle with seatbelts?
Are you willing to provide Home-to-Program transportation?
YesNo
State where Driver's license was issued
Licence Number
Expiration Date
If selected for a Host Home, Applicant must provide proof of current auto liabilty insurance with a minimum personal injury coverage of $300,000

Highest Level of Education
Other special training, e.g., QMAP, First Aid/CPR,skilled trade, LPN, college degrees & areas of study:

Name of Employer
Supervisor's Name
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
Email
Employment Start
Employment End Date
Annual Income
Reason(s) for leaving

Name of Employer
Supervisor's Name
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
Email
Employment Start
Employment End Date
Annual Income
Reason(s) for leaving

Employer's Name
Supervisor's Name
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
Email
Employment Start
Employment End Date
Annual Income
Reason(s) for leaving

Please give the following information for three personal references. Do not use relatives or employers listed above.

Name *
Phone *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email
Relationship *

Name *
Phone *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email
Relationship

Name *
Phone *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email
Relationship

Have you ever provided Host Home or Foster Care Services? *
YesNo
If yes, what Service Agency or County:
PREFERRED CLIENTS *
Please select clients that you can support in your homeMaleFemaleAges 18 to 30Any ageClients who are Independent with minimal supportClients with Behavioral/Mental Health challengesClients who are Medically Involved/FragileSex OffendersAny Client
Does anyone currently live in your home have a communicable disease? *
YesNo
Have you or any member of your household been convicted of a felony, child abuse, or an unlawful sexual offense?
YesNo
Have any individuals ever been removed from your home due to MANE allegations?
YesNo
Have you or has any member of your houshold been arrested for violations of the law other than minor traffic violations?
YesNo
Are you or any member of your household a smoker? *
YesNo
Do you have any experience or exposure to individuals with intellectual/developmental disabilities? If so, please describe. *
What qualities do you feel a Host Home should provide for an adult with developmental disabilities? *
When would you be available to begin providing care? *

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