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Real Care, Inc.Host Home Provider / Independent Contractor Application PacketUpdated July 10, 2017Please submit all application packets and supporting documentation to Real Care, Inc. at either:sarah@ Fax: 720.242.6282 In Person: 10200 West 44th AVE Suite 200 Wheat Ridge, CO 80033APPLICANT INFORMATIONFull Legal Name: FORMTEXT ?????Date: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? Zip: FORMTEXT ????? Phone: FORMTEXT ????? Email Address: FORMTEXT ????? Date Available: FORMTEXT ????? Social Security Number: FORMTEXT ????? Position applying for: FORMCHECKBOX Host Home FORMCHECKBOX Family Caregiver FORMCHECKBOX Direct Care Professional (Hourly) FORMCHECKBOX Respite (Please Circle: Hourly, In Home, Out of Home) FORMCHECKBOX Other : FORMTEXT ????? Are you a citizen of the U.S.? FORMCHECKBOX Yes FORMCHECKBOX NoIf not, are you authorized to work in the U.S.? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever worked for Real Care, Inc. previous to applying today? FORMCHECKBOX Yes FORMCHECKBOX No If so, when? FORMTEXT ????? Have you ever been convicted of a felony? FORMCHECKBOX Yes FORMCHECKBOX NoIf YES, please provide detailed explanation: FORMTEXT ?????EDUCATIONHigh School: FORMTEXT ?????From FORMTEXT ????? To: FORMTEXT ????? Address: FORMTEXT ?????Did you graduate? FORMCHECKBOX Yes FORMCHECKBOX NoCollege: FORMTEXT ?????From FORMTEXT ????? To: FORMTEXT ????? Address: FORMTEXT ?????Did you graduate? FORMCHECKBOX Yes FORMCHECKBOX No Degree: FORMTEXT ?????REFERENCES: Please list three (3) professional references, not personal references.Full Name: FORMTEXT ?????Phone: FORMTEXT ????? Company: FORMTEXT ????? Relationship: FORMTEXT ????? Address: FORMTEXT ????? Email Address: FORMTEXT ????? Full Name: FORMTEXT ?????Phone: FORMTEXT ????? Company: FORMTEXT ????? Relationship: FORMTEXT ????? Address: FORMTEXT ????? Email Address: FORMTEXT ????? Full Name: FORMTEXT ?????Phone: FORMTEXT ????? Company: FORMTEXT ????? Relationship: FORMTEXT ????? Address: FORMTEXT ????? Email Address: FORMTEXT ????? Previous EmploymentCompany: FORMTEXT ?????Phone: FORMTEXT ????? Address: FORMTEXT ?????Supervisor: FORMTEXT ????? Job Title(s): FORMTEXT ????? Starting Salary: FORMTEXT ?????Ending Salary: FORMTEXT ????? Responsibilities: FORMTEXT ????? Date(s) of Employment: FORMTEXT ????? Reason for Leaving: FORMTEXT ????? Company: FORMTEXT ?????Phone: FORMTEXT ????? Address: FORMTEXT ?????Supervisor: FORMTEXT ????? Job Title(s): FORMTEXT ????? Starting Salary: FORMTEXT ?????Ending Salary: FORMTEXT ????? Responsibilities: FORMTEXT ????? Date(s) of Employment: FORMTEXT ????? Reason for Leaving: FORMTEXT ????? Company: FORMTEXT ?????Phone: FORMTEXT ????? Address: FORMTEXT ?????Supervisor: FORMTEXT ????? Job Title(s): FORMTEXT ????? Starting Salary: FORMTEXT ?????Ending Salary: FORMTEXT ????? Responsibilities: FORMTEXT ????? Date(s) of Employment: FORMTEXT ????? Reason for Leaving: FORMTEXT ????? QUESTIONS BELOW MUST BE ANSWERED OR APPLICATION WILL NOT BE PROCESSED-----------------------------------------------------------------------------------------------------------------------------------------------------------------------Have you ever been the subject of an investigation for suspected Mistreatment, Abuse, Neglect and / or Exploitation related to an individual with a disability or other at-risk person (including youth). FORMCHECKBOX Yes FORMCHECKBOX NoIf YES, please provide detailed explanation: FORMTEXT ?????Which CCB Completed the investigation? FORMTEXT ?????Was the allegation substantiated / founded? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have any other family members who are also host home providers? FORMCHECKBOX Yes FORMCHECKBOX NoIf YES, please provide detailed explanation including name and agency working with: FORMTEXT ?????Do you provide respite / supervision to the individuals residing in home(s) (Listed Above)? FORMCHECKBOX Yes FORMCHECKBOX No If YES, please provide detailed explanation including where you provide respite and frequency: FORMTEXT ?????Do you operate any host home(s), other than at the address listed above on this application? FORMCHECKBOX Yes FORMCHECKBOX No If YES, please provide detailed explanation including where the host home is and how you will meet the supervision requirements of all individuals receiving services in host homes you operate? FORMTEXT ????? Please list the initials of the individuals receiving services and the agency you are contracted with to provide these services: FORMTEXT ?????Which CCB’s have you worked with previously? FORMTEXT ?????Disclaimer and SignatureI certify that my above answers are true and accurate to the best of my knowledge. If this application leads to a contractual relationship, I understand that falsifying or misleading information in my application or interview can or may result in termination of contract without further notice.Signature: FORMTEXT ?????Date: FORMTEXT ????? CHECKLIST FOR NEW PROVIDERS / CAREGIVERSITEMS NEEDED FOR POTENTIAL PROVIDERS / CAREGIVERS PLACEMENT______Application______Reference Checks______Background Check Release(s)______Driver’s License______Second form of ID (Social Security Card, Birth Certificate, Military ID…)______Homeowner’s Insurance Coverage / Renter’s Insurance______Automobile Insurance______Professional Liability Insurance ()______List of Other Individuals In Services Living in the Home and Name of Agency they are with______Motor Vehicle Report () ______Motor Vehicle Inspection (This can be the printout from your last oil change) ______HUD InspectionNECESSARY TRAINING PRIOR TO PLACEMENT______CPR______First Aid______QMAP (If Applicable)______I-Train FORMTEXT ?????175041905Last Name17145192405 FORMTEXT ?????First Name FORMTEXT ????? FORMTEXT ?????3205397381000178355080Middle Initial / Name Date of Birth (DOB) FORMTEXT ????? FORMTEXT ?????3207744604600171455080Social Security Number (SSN) Gender: Male or Female Please list the last 5 years of Residence including City/State and County: FORMTEXT ?????175043810 FORMTEXT ?????175045080 FORMTEXT ?????171455052 FORMTEXT ?????184151270 FORMTEXT ?????171451850This information is used for background check purposes only.As a condition of employment/contract, Real Care Inc. requires a background check on all employees and/or contractors.I, FORMTEXT ?????right762000authorize Real Care, Inc. to perform a Colorado Bureau of Investigation (CBI) background check and Federal Bureau of Investigation (FBI), if deemed necessary. FORMTEXT ?????left3810Employee/Applicant SignatureDateHOST HOME PROVIDER INFORMATION SHEETAgency Name: Real Care, Inc. Agency Contact Person: Sarah Crocket - sarah@ Agency Contact Phone: 303.284.5818Name: FORMTEXT ?????Date Completed: FORMTEXT ?????Email Address: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????Phone #: FORMTEXT ?????Alternate Phone #: FORMTEXT ?????Please verify provider name including all pseudonyms and ‘also know as’ (AKA) names.Area of Town: FORMCHECKBOX Denver FORMCHECKBOX Montbello FORMCHECKBOX Green Valley Ranch FORMCHECKBOX Aurora FORMCHECKBOX Lakewood FORMCHECKBOX Littleton FORMCHECKBOX Arvada FORMCHECKBOX Northglenn FORMCHECKBOX Westminster FORMCHECKBOX Parker FORMCHECKBOX Thornton FORMCHECKBOX OtherMajor cross streets (i.e. Colfax and Havana or Iliff and I-225): FORMTEXT ????? PROVIDER EXPERIENCEYears as a Host Home Provider: FORMTEXT ????? or FORMCHECKBOX NewPlease give detailed description of your personal experience supporting individuals with intellectual / developmental disabilities: FORMTEXT ?????Please check the areas of individual support that you feel you are able to provide support to: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Single Individual FORMCHECKBOX Married Couple FORMCHECKBOX Religious Preference: FORMTEXT ?????Attend Church: FORMTEXT ????? (day of week, time, etc.) FORMCHECKBOX Behavioral Support FORMCHECKBOX Physical Aggression FORMCHECKBOX Verbal Aggression FORMCHECKBOX Property Destruction FORMCHECKBOX Sexualized Behavior FORMCHECKBOX Elopement FORMCHECKBOX Boundary Concerns FORMCHECKBOX Mental Health Support FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Medical FORMCHECKBOX Personal Care FORMCHECKBOX Feeding FORMCHECKBOX Bathing FORMCHECKBOX Toileting / Changing FORMCHECKBOX Transferring FORMCHECKBOX Frequent Medical appointments FORMCHECKBOX G-Tube FORMCHECKBOX Aspiration FORMCHECKBOX Frequent Positioning FORMCHECKBOX CNA FORMCHECKBOX RN Other languages: FORMTEXT ?????Please provide any information that you think would be helpful about your experience: FORMTEXT ?????TYPE OF HOMEPlease Describe Your Home: FORMCHECKBOX House FORMCHECKBOX Apartment FORMCHECKBOX Townhouse FORMCHECKBOX Other: ______________# of Bedrooms Available: ___________# of Bathrooms: _____________Is your home wheelchair accessible? FORMCHECKBOX Yes FORMCHECKBOX NoDoes your home have stairs? FORMCHECKBOX Yes FORMCHECKBOX NoDo you own pets? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Dog(s) Description: FORMTEXT ????? FORMCHECKBOX Cat(s) Description: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX TransportationDescription of Vehicle: FORMTEXT ????? FORMCHECKBOX WC accessiblePlease list all individuals in the home:(double click on shaded boxes to enter information) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name Relationship to HHPAgeMale / FemaleAre any of the above individuals person with disabilities? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please name: FORMTEXT ?????Is the individual with another CCB? If yes, please select one: FORMCHECKBOX RMHS FORMCHECKBOX DP FORMCHECKBOX NMCS FORMCHECKBOX DDRC FORMCHECKBOX Other: FORMTEXT ?????If you become a host home provider, do you plan to maintain outside employment? FORMCHECKBOX Yes FORMCHECKBOX NoPlease give a brief description of you, your family, your household, neighborhood, etc. that we can use to respond to referrals on your behalf. FORMTEXT ????? ................
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