Host Home Fillable Form - Progressive Community Network

Today's Date:

Name

First

Middle

Last

Email

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Address

Address Line 1

Address Line 2

City

State

Zip Code

Is this address your primary home where services will be provided?

Yes
No

Phone Number:

Best time to reach you?

Morning
Afternoon

Best method to contact you?

Phone Call
Text Message
Email

Household:

Are there other household members living in your home?

Yes
No

List all other people living in your household.

Click “Add another household member” to include more.

Full Name

Age:

Relationship:

Do any of these people pay you to live in your home?

Yes
No

Housing Type:

Please list other household type:

Do you own or rent?

Own
Rent

Number of bedrooms?

Number of bathrooms?

Would you permit adaptations for any necessary handicap devices?

Yes
No

Does your home have a wheelchair ramp entrance?

Yes
No

Are there handrails and grab bars?

Yes
No

Is the bedroom for the Member on the main floor?

Yes
No

Would the Member have wheelchair access to all of the home?

Yes
No

Is the bathroom accessible with grab bars, raised toilet seat, wheel in shower, etc?

Yes
No

Please provide any additional information which describes the degree to which your home is wheelchair accessible inside and out:

Do you have pets?

Yes
No

List pets in your home:

Click “Add Another Pet” to include additional pets.

Pet Type & Breed:

e.g., dog, cat, bird

Age of Pet:

Pet temperament (optional but very helpful)

Would you need to change your current residence before starting a Host Home?

Yes
No

How much notice would you need to move, if necessary?

<30 Days
30-60 Days
>60 Days

Do you have a vehicle?

Yes
No

List the make, model, and year of your vehicle:

How many passengers can ride in the vehicle?

Do you have a valid driver's license?

Yes
No

Please list state issued, drivers license number, and expiration date:

If selected as a Host Home, you must provide proof of current auto liability insurance with minimum coverage of $300,000.

Education Information:

College:

High School Graduate:

Yes
No

GED or High School Equivalency:

Yes
No

Do you speak any other languages fluently?

Yes
No

Languages spoken:

Do you have any specialized training? (Check all that apply)

Describe other training or certifications:

Employment History:

List your most recent jobs from the past 5 years, starting with your current or most recent position.

If a field does not apply, enter “N/A”.

Name of Employer:

Phone:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Supervisors Name:

Employment Dates:

Job Title:

Job Duties:

Reason for Leaving:

Personal References:

List at least 3 personal references (not family). Include people who can speak to your character, such as a former employer, coworker, or community member.

Please ensure your references are aware they may be contacted.

Full Name:

Phone:

Email:

Relationship:

Full Name:

Phone:

Email:

Relationship:

Full Name:

Phone:

Email:

Relationship:

Pre-interview Questionnaire:

A background check is required for selected applicants and for anyone age 18 or older living in the home.

Have you worked for Progressive Community Network before?

Yes
No

When did you work here?

Have you previously been a Host Home Provider?

Yes
No

Are you currently a Host Home Provider?

Yes
No

If yes, what company?

Have you or anyone living in your household been convicted of a felony, child abuse, or a sexual offense?

Yes
No

Please provide details:

Have you or anyone living in your household been arrested for anything other than minor traffic violations?

Yes
No

Please explain:

This information does not automatically disqualify you.

What motivates you to become a Host Home Provider?

What qualities are most important for a Host Home to provide a safe, respectful, and supportive environment?

Do you have any experience or involvement with the developmental disability community?

Yes
No

If yes, please describe:

How long do you plan to be a Host Home Provider?

Host Home contracts may be renewed and typically align with the agency’s budget year.

When would you be available to begin providing care?

Do you have any regular commitments that would require you to be away from home during the day or evening?

Yes
No

If yes, please describe:

Could you care for an adult who requires 24/7 supervision?

Yes
No

I could best support a person with the following care needs (choose one, or all that apply):

Behavioral/Mental Health
Medically Involved/Fragile
Independent with Minimal Supports

Of the behaviors listed below, select all that you would be willing to work with:

Do you have experience with digital documentation?

Yes
No

List platforms or tools you’ve used:

Is there a particular individual for whom you are interested in providing services?

Yes
No

If yes, please list full name:

Full Name:

I certify that I have truthfully answered the above questions to the best of my ability. I understand that providing false or misleading information may result in the cancellation of my Host Home Application. Failure to complete any section of this application may be cause for you not to be considered further.

Yes
No

I understand that I will be contacted if the team decides to move forward and that I should not call for updates, as this will not speed up the process.

Yes

Signature

Clear Signature

How did you hear about us?

Please specify:

Create unforgettable moments
with our exceptional guidance

Household:

List all other people living in your household.

List pets in your home:

List the make, model, and year of your vehicle:

Please list state issued, drivers license number, and expiration date:

If selected as a Host Home, you must provide proof of current auto liability insurance with minimum coverage of $300,000.

Education Information:

Employment History:

List your most recent jobs from the past 5 years, starting with your current or most recent position.

Personal References:

List at least 3 personal references (not family). Include people who can speak to your character, such as a former employer, coworker, or community member.

Pre-interview Questionnaire:

Business Hours:

Menu:

Get in touch
with us today!

Create unforgettable moments with our exceptional guidance

Household:

List all other people living in your household.

List pets in your home:

List the make, model, and year of your vehicle:

Please list state issued, drivers license number, and expiration date:

If selected as a Host Home, you must provide proof of current auto liability insurance with minimum coverage of $300,000.

Education Information:

Employment History:

List your most recent jobs from the past 5 years, starting with your current or most recent position.

Personal References:

List at least 3 personal references (not family). Include people who can speak to your character, such as a former employer, coworker, or community member.

Pre-interview Questionnaire:

Business Hours:

Menu:

Get in touch with us today!

Create unforgettable moments
with our exceptional guidance

Get in touch
with us today!