Enhanced Family Care Application

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Name

First

Last

Your Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Are you authorized to work in the U.S.?

Yes
No

Do you have a valid driver's license?

Yes
No

Employment History

List the most recent employer first

Employer

Employer Phone

Employer Email

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer Name (2)

Employer Phone (2)

Employer Email (2)

Employer Address (2)

Address Line 1

Address Line 2

City

State

Zip Code

Employer Name (3)

Employer Phone (3)

Employer Email (3)

Employer Address (3)

Address Line 1

Address Line 2

City

State

Zip Code

May we contact the above employers for references?

Yes
No

Education

Highest Grade Completed

High School/GED
College
Post-collegiate

School/College

Degree/Diploma

City/State

Please detail experience, skills, or abilities related to this position

Household Information

ls your home accessible to wheelchairs?

Yes
No

Are you available 24/7?

Yes
No

Are you available 24/7? (copy)

Yes
No

Do you prefer someone who has a day program?

Yes
No

Please list everyone who resides in your home:

Include NAME, AGE, and RELATION TO APPLICANT

Have you, or anyone in your household been convicted of a misdemeanor?

Yes
No

If yes, please explain:

Have you, or anyone in your household been convicted of a felony?

Yes
No

If yes, please explain:

Do you, or anyone in your household own firearms or other weapons?

Yes
No

If yes, please explain:

Do you consider yourself to be more of a:

Leader
Follower
Teacher

Please explain your choice

Do you have any pets?

Yes
No

younger, abilities or

If 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 References

Do not include relatives or previously listed supervisors

Name

First

Last

Years Known

Relationship

Phone

Email

Name (2)

First

Last

Relationship (2)

Years Known (2)

Phone (2)

Email (2)

Name (3)

First

Last

Relationship (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?

Yes
No

If yes, may we contact you at a later date?

Yes
No

By 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.

Date