Enhanced Family Care Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastYour AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Are you authorized to work in the U.S.? *YesNoDo you have a valid driver's license? *YesNoEmployment HistoryList the most recent employer firstEmployerEmployer PhoneEmployer EmailEmployer AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployer Name (2)Employer Phone (2)Employer Email (2)Employer Address (2)Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployer Name (3)Employer Phone (3)Employer Email (3)Employer Address (3)Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMay we contact the above employers for references?YesNoEducationHighest Grade Completed *High School/GEDCollegePost-collegiateSchool/College * you Employer good Degree/Diploma *City/State *Please detail experience, skills, or abilities related to this positionHousehold Informationls your home accessible to wheelchairs? *YesNoAre you available 24/7? *YesNoAre you available 24/7? (copy) *YesNoDo you prefer someone who has a day program? *YesNoPlease list everyone who resides in your home: *Include NAME, AGE, and RELATION TO APPLICANTHave you, or anyone in your household been convicted of a misdemeanor? *YesNoIf yes, please explain:Have you, or anyone in your household been convicted of a felony? *YesNoIf yes, please explain:Do you, or anyone in your household own firearms or other weapons? *YesNoIf yes, please explain:Do you consider yourself to be more of a: *LeaderFollowerTeacherPlease explain your choice *Do you have any pets? *YesNoIf YES, please list:What type of individual would be a good fit in your home (male, female, older, younger, active, smoker/non-smoker, etc.)? *Personal or Business ReferencesDo not include relatives or previously listed supervisors Name *FirstLastYears Known *Relationship *PhoneEmail *Name (2) *FirstLastRelationship (2) *Years Known (2) *Phone (2)Email (2) *Name (3) *FirstLastRelationship (3) *Years Known (3) *Phone (3)Email (3) *How did you hear about Crotched Mountain Community Care? *What made you interested in becoming a Home Provider? *If a Home Provider arrangement does not work out for you, are you interested in other employment opportunities with Crotched Mountain Community Care? *YesNoIf yes, may we contact you at a later date? *YesNoBy entering my full name below, I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of this application or immediate termination of employment. *DateSubmit Skip back to main navigation