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  • MEMORANDUM 

  • TO: Prospective Host Home/Alternative Care Provider 

    FROM: Adult Residential Services Department 

    SUBJECT: Host Home Application 

     

    Thank you for your interest in becoming a Host Home Provider/Alternative Care Provider for Laradon’s Adult Residential Services Department. Enclosed is a Laradon Host Home Provider/Alternative Care Provider Questionnaire and Employment/Contractor Inquiry Release/Authorization form. Please complete all forms and return to the address listed below so that we can begin your application process. You will only be considered for a possible Host Home Provider/Alternative Care Provider when all forms are returned completely filled out. 

    Completion of this questionnaire and background checks do not guarantee, imply or contract you as a Host Home Provider/Alternative Care Provider. If you are chosen as a prospective Host Home Provider/Alternative Care Provider, the Placement Coordinator will notify you.

  • LARADON HOST HOME / RESPITE CARE PROVIDER QUESTIONNAIRE 

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  • Start with your most recent job or experience. Include any job-related military service assignments and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, handicap, or other protected status.

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  • I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application. In the event that a Host Home agreement is reached, I understand that false or misleading information given on this questionnaire or during the interview(s) may result in the immediate cancellation of all agreements. 

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  • Addendum To Host Home/Respite Care Questionnaire

    Please Complete The Following Questions 

  • I certify that I have to the best of my ability truthfully answered the above questions (Specifically #1-5).

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  • PROVIDER/SUPPORT PERSON INVENTORY

    When people live together there is a greater chance of success if there are common interests. This inventory will be utilized to assist Laradon in making the best possible match.

  • Please check the appropriate number for each interest/activity.

    1 = Often
    2 = Sometimes
    3 = Rarely
    4 = Never
    5 = Would like to

  • LEISURE  (AT HOME)

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  • RECREATION

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  • Should be Empty: