Shared Living Application

Applicant Information

Date of Application *

First Name *

Middle Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone *

Email Address *

Applicant Information Continued

Disclaimer

Some states require background checks and sex offender registry checks for anyone else living in the home who is 14 years of age or older. The following information is necessary to be in compliance with state-specific regulations. Vista Care will only run background checks on those within the required age range based on the state’s regulations.

*The Provider understands that they must notify Vista Care if anyone else moves into the home after execution of the Independent Contractor Agreement. Vista Care retains the right to acquire, require, or request subsequent background or motor vehicle records checks during the term of the Independent Contractor Agreement.

DO NOT INCLUDE ANYONE WITH DEVELOPMENTAL DISABILITIES RECEIVING SERVICES IN THE HOME.

Additional Person Living In The Home #1

First Name

Middle Name

Last Name

Social Security Number0 / 9

Date Of Birth

Current Age0 / 3

Additional Person Living In The Home #2

First Name

Middle Name

Last Name

Social Security Number0 / 9

Date Of Birth

Current Age0 / 3

Additional Person Living In The Home #3

First Name

Middle Name

Last Name

Social Security Number0 / 9

Date Of Birth

Current Age0 / 3

Additional Person Living In The Home #4

First Name

Middle Name

Last Name

Social Security Number0 / 9

Date Of Birth

Current Age0 / 3

Additional Person Living In The Home #5

First Name

Middle Name

Last Name

Social Security Number0 / 9

Date Of Birth

Current Age0 / 3

Additional Person Living In The Home #6

First Name

Middle Name

Last Name

Social Security Number0 / 9

Date Of Birth

Current Age0 / 3

By Whom?

Other

Are you authorized to work in the U.S.? (Proof of citizenship or legal immigration will be required) *

Have you or a family member ever been employed or contracted by Vista Care? If yes, when? *

If Yes, When

Have you or anyone else living in the home ever had a substantiated abuse or neglect charge against you involving someone considered at risk or someone with a disability? If yes, please explain. *

If yes, please explain

Is there anything that would interfere with your ability to contract with Vista Care or perform the duties required by Vista Care and/or local, state, or federal regulatory agencies? *

Education

School Name

Location

Degree Received *

Other training, certifications, or licenses held:

Professional References

First Name *

Last Name *

Email Address *

Phone *

First Name *

Last Name *

Email Address *

Phone *

First Name *

Last Name *

Email Address *

Phone *

Employment History

Employer Name

Dates Employed

Phone0 / 10

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Position

Supervisor’s Name and Title

Reason for Leaving

May We Contact *

Employer Name

Dates Employed

Phone0 / 10

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Position

Supervisor’s Name and Title

Reason for Leaving

May We Contact *

Employer Name

Dates Employed

Phone0 / 10

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Position

Supervisor’s Name and Title

Reason for Leaving

May We Contact *

Length of time at current home address: *

Length of time at previous home address: *

Have you ever been certified, or approved, to be a Shared Living or Host Home Provider? List agency, state, and dates. *

Have you ever applied to be a foster home or childcare provider? List agency, state and dates. *

Have you ever been denied a certification or license to be a Shared Living or Host Home Provider? List agency, state, and dates. *

Is there a swimming pool, hot tub, or trampoline at the home? If so, please explain the measures you will take to ensure safety. *

Are there any weapons in the home? What kind? Please explain the measures you will take to ensure safety. *

Do you have pets? What type? How many? List any past or current aggression concerns or unfriendliness with your pets and how you will ensure safety. *

Do you have an in-home business? If yes, please describe. *

Please describe any long-term care experience, including residential, childcare, foster care, day program, etc. *

Why do you want to be a Shared Living or Host Home Provider to a person with a developmental disability? *

Residence and Environmental Information

Please complete the following information about your living environment:

Choose Housing Type:

Number Of Bedrooms0 / 2

Number Of Bathrooms0 / 2

The person in services will be required to have their own private bedroom. Can you accommodate this?

On what level of the home would the bedroom of the person you’re supporting be located? *

Would the person you’re supporting have a private bathroom?

On what level of the home would the bathroom of the person you’re supporting be located? *

Is the home wheelchair accessible throughout the living and general use areas?

Is the home wheelchair accessible for entry and exit?

Are bathrooms wheelchair accessible and ADA compliant?

Indicate the location and number of smoke detectors, carbon monoxide detectors, and fire extinguishers in the home.

First Location *

Number of Smoke Detectors *0 / 2

Number of Fire Extinguishers *0 / 2

Number of Carbon Monoxide Detectors *0 / 2

Second Location

Number of Smoke Detectors0 / 2

Number of Fire Extinguishers0 / 2

Number of Carbon Monoxide Detectors0 / 2

Third Location

Number of Smoke Detectors0 / 2

Number of Fire Extinguishers0 / 2

Number of Carbon Monoxide Detectors0 / 2

Fourth Location

Number of Smoke Detectors0 / 2

Number of Fire Extinguishers0 / 2

Number of Carbon Monoxide Detectors0 / 2

Fifth Location

Number of Smoke Detectors0 / 2

Number of Fire Extinguishers0 / 2

Number of Carbon Monoxide Detectors0 / 2

Home Description *

Neighborhood Description *

Would you be able to provide assistance with the following unique needs?

Poor or non-existent self-help skills (feeding, toileting, etc.) *

Seizure disorders *

Non-ambulatory (requiring a wheelchair, walker, or assistive device *

24-hour line-of sight supervision *

Remodeling to improve accessibility *

Provide the person you’re supporting with a bedroom lock and key *

Mild to moderate behavioral needs *

Severe behavioral needs *

Mild to moderate medical needs *

Severe medical needs *

Do you have experience with any of the following unique behavioral needs?

Verbal abuse (yelling, cursing, name-calling or other inappropriate verbalizations) *

Physical aggression (hitting, biting, scratching, pinching others) *

Self-aggression (hitting, biting, scratching, pinching self) *

Inappropriate sexual behaviors or sexual offenders *

Elopement (running away) *

Spitting *

Stereotypical behaviors (arm flapping, rocking, hand-waving, spinning, etc.) *

Property destruction (throwing household items/furniture, damaging walls, etc.) *

Pica (ingestion of inedible items) *

Lying or stealing *

Excessive or prolonged screaming *

Are there any behavioral needs you feel you cannot tolerate at all or will not allow in your home? *

If yes to the question above, please explain:

Do you have experience with any of the following unique medical needs?

Non-ambulatory (uses wheelchair) *

Semi-ambulatory (uses walker, cane, braces, or other assistive devices) *

Blindness *

Deafness *

Seizures *

Diabetes *

Specialized dietary needs (cut, chopped, minced, pureed, etc.) *

Non-verbal or doesn’t use words to communicate *

Intensive medical needs (catheter, tube-feeding, etc.) *

List or explain any training or certifications you have had in working with the above unique behavioral or medical needs: *

Disclaimer, Consent, and Signature

Please Read Carefully

Applicant Name

Applicant Signature: *

Todays Date *

Save as Draft

Shared Living/Host Home Provider Application

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