Contract Opportunity: Shared Living Provider (1099)

First Name, Last Name, Email, Phone, Resume/CV, Location

• Do you have a High School Diploma or GED? choose one
• First Name
• Last Name
• Email
• Phone Number
• Aspire Living & Learning is proud of the excellent and individualized services we provide to children and adults with disabilities. Our team members are committed to helping others live their best lives. What do you hope to add to the Aspire Living & Learning team? written answer
• Do you have any experience working with people with disabilities? choose one
• If yes, please describe what you liked best about the experience- written answer · optional
• Are you currently a home care provider for another agency? choose one
• If yes, which agency? written answer · optional
• Which of the following trainings/certification do you have (please check all that apply)? choose any · optional
• Would you have any problems working with verbally or physically aggressive individuals? Yes or No - If you answered YES please explain further- written answer
• Are you willing and able to assist and instruct in areas of personal care/hygiene? YES or NO- If you answered NO please explain further- written answer
• Are you willing and able to assist individuals in lifting and transfer, including a weight of up to 75 lbs? YES or NO. If NO, please explain further- written answer
• What city and state do you live in? written answer
• Street Address and zip code written answer
• Is your home handicap/wheelchair accessible? choose one
• How many empty bedrooms do you have?
• Where are the empty bedroom(s) located? written answer
• Are the empty bedrooms handicap/wheelchair accessible? written answer
• Do you have any pets? If so, what kind and how many? written answer
• Do you have HARD-WIRED, interconnected smoke detectors? choose one
• Are you 18 years of age or older? choose one
• Do you have any children living the home? If yes, How many and what are their ages? written answer
• How many people live in your home, and what are their ages? written answer
• Do you expect any changes to occur in your household. or lifestyle, within the next two years (for example: moving to another town, addition of a baby, family members moving in or out of the home)? If Yes, please explain further- written answer
• Do you have any reason to believe that you may be called away from home for a long period of time (for example, to care for a sick relative for a month)? written answer
• Do you have a valid driver's license? choose one
• If contracted with us, do you have a reliable vehicle?
• Do you have insurance coverage on your vehicle? choose one
• Do you or any of your household members smoke? If yes, do they smoke inside or outside of the house? written answer
• Have you, or any member of your household, had any convictions or history of child abuse, neglect or mistreatment? If YES, please explain further- written answer
• Have you, or any other member of your household, ever been imprisoned, on probation, convicted and/or fined for any violation of any law? If YES, please explain further- written answer
• Has a complaint of client abuse or mistreatment ever been filed against you or any member of your household? If YES, please explain further- written answer
• Is there a restraining order against you or anyone in your household? choose one
• Do you or anyone in your household have a history, or current problem with substance abuse? choose one
• Are there any other present or past circumstances (for example, health problems, anger management issues, etc.) whose presence or recurrence would affect a person living in your home? If there is please explain further- written answer
• What prompted you to pursue becoming a residential provider for a person with disabilities? written answer
• What kinds of training, education, or personal experiences have you had that you feel would prepare you to live with a disabled individual? written answer
• Do you have a preference regarding the gender of the person you support? choose any
• Do you have a preference regarding the physical ability of the person you support? If YES, please explain- written answer
• How will it affect your family to have someone with special needs living with you? written answer
• Will you feel comfortable with this person in public places? choose one
• What kind of behaviors might you find embarrassing? written answer
• In one word, how would you describe the relationship you would have with this person with special needs?
• What is your favorite way to relax? written answer
• How do you and members of your household resolve conflict? written answer
• What do you consider to be your worst habit? written answer
• Do you cook? If yes, what type of food do you enjoy cooking? written answer
• What is your favorite thing to do that doesn't cost money? written answer
• What household chores do you like the best? Least? written answer
• Describe a typical week day evening in your home. written answer
• What are some things that stress you out the most on a daily basis? written answer
• Describe a typical weekend day in your home. written answer
• How do you express anger? written answer
• Do you mind others smoking cigarettes around you? choose one
• What do you consider to be your best attribute?
• Do you store firearms in your homes? YES or NO- If Yes- How are they stored? written answer
• Do you have any limitations (of any kind) that you feel we should know about? written answer
• Do you have any apprehensions about becoming a provider? written answer
• If offered a Home Care Providership, when are you available to start contracting with Aspire Living & Learning? written answer
• The following statement must be read and signed by you in order for Aspire Living & Learning to enter into a contract with you: I hereby certify that this disclosure form and the attached resume contain no false information and are completed to the best of my knowledge. I am aware that if an investigation reveals misrepresentation or falsification, Aspire Living & Learning may choose not to contract with me or to terminate such contract without notice. - Please Type Name- written answer
• Todays Date-
• Reference- Please list 3 references- We will need their full name, Where you know them from, Phone # and email address. written answer
• Were you referred by a current employee? If so, please include their full name below. optional
• Are you a current employee or contracted with Aspire Living & Learning? choose one