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Enhanced Family Care Application

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Name
Your Address
Are you authorized to work in the U.S.?
Do you have a valid driver's license?

Employment History

List the most recent employer first
Employer Address
Employer Address (2)
Employer Address (3)
May we contact the above employers for references?

Education

Highest Grade Completed

Household Information

ls your home accessible to wheelchairs?
Are you available 24/7?
Are you available 24/7? (copy)
Do you prefer someone who has a day program?
Include NAME, AGE, and RELATION TO APPLICANT
Have you, or anyone in your household been convicted of a misdemeanor?
Have you, or anyone in your household been convicted of a felony?
Do you, or anyone in your household own firearms or other weapons?
Do you consider yourself to be more of a:
Do you have any pets?

Personal or Business References

Do not include relatives or previously listed supervisors
Name
Name (2)
Name (3)
If a Home Provider arrangement does not work out for you, are you interested in other employment opportunities with Crotched Mountain Community Care?
If yes, may we contact you at a later date?