Home Provider Application

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Thank you for your interest in applying to be a Home Provider with Crotched Mountain Foundation. Please fill out the form below to submit your application securely.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Are you authorized to work in the US? *

Yes
No

Do you have a valid driver's license? *

Yes
No

Employment History

List the most recent employer first.

Employer (1)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Dates Employed

Supervisor's Name

Your Position

Reason for Leaving

Employer (2)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Dates Employed

Supervisor's Name

Your Position

Reason for Leaving

Employer (3)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Dates Employed

Supervisor's Name

Your Position

Reason for Leaving

May we contact the above employers for references? *

Yes
No

Education

Highest Grade Completed *

School/College

City/State

Degree/Diploma

• Experience, skills, or abilities related to this position?: *

Household

Is your home accessible to wheelchairs? *

Yes
No

Are you available 24/7? *

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
Teacher
Follower

Why?

Do you have any household rules that would need to be considered? *

Yes
No

If yes, please list:

Do you have any pets? *

Yes
No

If yes, please list:

What type of individual would be a good fit in your home? *

E.g., male, female, older, younger, active, smoker/non-smoker, etc.

Personal or Business References

Name (Reference 1) *

First

Last

Relationship *

Years Known *

Phone

Email *

Name (Reference 2) *

First

Last

Years Known *

Phone

Email

Name (Reference 3) *

First

Last

Years Known *

Phone

Email *

How did you hear about Crotched Mountain? *

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 Foundation? *

Yes
No

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

Yes
No

By signing below, I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief and that if information has been falsified it could result in termination of any future contract. *

Your Name

Date *

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