Host Home Fillable Form - Progressive Community Network

Today's Date:

Name

First

Middle

Last

Email

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?

Total rooms?

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 feel a Host Home should provide for a disabled adult?

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

Introduce Yourself:

This section helps us get to know you better so we can make thoughtful matches between individuals seeking host homes and contractors like you who are passionate about making a difference. Share a bit about yourself, your household, and what makes your home environment unique. Whether it’s your hobbies, daily routines, or family traditions, these details help us create connections that foster comfort, trust, and a sense of belonging for everyone involved.

Why do you want to open your home up to an individual with disabilities?

Please describe what an average day in your/your family’s life looks like.

What is your religious/faith base, if any?

What are your interests and hobbies?

Describe your home.

Describe your neighborhood.

What are your family’s traditions?

What does your “perfect” day look like?

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: