Host Home Fillable Form - Progressive Community Network

Today's Date:

Name

First

Middle

Last

Email

Sign-up for our newsletter?

Get inspiring stories, event updates, and news from the PCN community—straight to your inbox. By subscribing, you consent to receive email updates from Progressive Community Network. You may opt out at any time using the unsubscribe link in our emails.

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

Other Household Members:

List ALL members living in your household, their age, and their relationship to you.

Name

First

Last

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 type of pets:

Breed:

Age of Pet:

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

Please list the make, model, and year of your vehicle:

Make:

Model:

Year:

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:

State Issued:

Driver's License Number:

Expiration Date:

If selected for a Host Home, the applicant must provide proof of current auto liability insurance with a minimum personal injury 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

Language(s):

Other specialized training(s)? (Check all that apply)

Please explain other:

Employment History:

Please begin with the most current, up to the last 5 years.

Name of Employer:

Phone:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Supervisors Name:

First

Last

Length of Employment:

List dates from & to.

Job Title:

Job Duties:

Reason for Leaving:

Personal References:

Please list at least three personal references. Include name, phone number, email address and relationship to you.

Name:

First

Last

Phone:

Email:

Relationship:

Pre-interview Questionnaire:

Have you been employed by Progressive Community Network previously?

Yes
No

A background check will be conducted on applicants selected for Host Home Provider .

A background check is also required for anyone 18 or older living in the home.

If yes, when?

Have you previously been a Host Home Provider?

Yes
No

Are you currently a Host Home Provider?

Yes
No

If yes, please list the company:

Have you or any member of your household been convicted of a felony, child abuse, or an unlawful sexual offense?

Yes
No

If yes, name of person & related offense:

Have you or any member of your household been arrested for violations of the law other than minor traffic violations?

Yes
No

If yes, please explain:

What motivates you to become a Host Home Provider?

What qualities do you believe are most important for a Host Home to offer in order to support the safety, dignity, and overall well-being of an adult with disabilities?

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

Yes
No

If yes, please describe:

Progressive Community Network’s Host Home contracts may be renewable and are written to coincide with the agency's budget year. How long do you anticipate being a Host Home Provider?

When would you be available to begin providing care?

Do you have any obligations that would require you to be away regularly 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

If yes, which platform?

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

Yes
No

If yes, please list name:

Name

First

Last

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

Signature

Clear Signature

How did you hear about us?

Other:

Create unforgettable moments
with our exceptional guidance

List ALL members living in your household, their age, and their relationship to you.

List type of pets:

Please list the make, model, and year of your vehicle:

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

Please begin with the most current, up to the last 5 years.

Please list at least three personal references. Include name, phone number, email address and relationship to you.

Business Hours:

Menu:

Get in touch
with us today!

Create unforgettable moments with our exceptional guidance

List ALL members living in your household, their age, and their relationship to you.

List type of pets:

Please list the make, model, and year of your vehicle:

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

Please begin with the most current, up to the last 5 years.

Please list at least three personal references. Include name, phone number, email address and relationship to you.

Business Hours:

Menu:

Get in touch with us today!

Create unforgettable moments
with our exceptional guidance

Get in touch
with us today!