Extended Family Home

Date:

Name: (Required)

Current RVS Employee?

Address:

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State:

City:

Phone:

Home

Work

Cell

Email:

Place of Employment:

May we contact your current employer?

Address:

State:

City:

Occupation/Military:

Hours and Days Worked:

Hobbies, Special Interests, Membership of Clubs and Organizations?

Have you been a care provider before?

If yes, please give dates and details:

Do you have a valid Drivers License?

Would you be willing to provide local transportation for outings, Dr. appointments, ETC?

Do you rent or own your home?

(Rent) Name of landlord:

Phone:

Household Members:

Name(s):

Date(s) of birth:

Occupation(s):

Relationship:

Education/Experience

What is the highest level of education you have completed?

What experience (Schooling and/or work skills) do you have that would enhance your ability to care for an individual with a developmental disability?

Employment History

Briefly describe jobs over the past 5 years, beginning with your current occupation. Include name of employer, address, and dates of employment, your work title, supervisor and phone number, a brief description of responsibilities, and reason for leaving.

Violations

Have you ever been arrested for anything?

If yes, please explain (Provide a brief description and dates)

Living Arrangments

What would the living arrangements be for the individual?

Would you accept an individual who: (Please check all that apply)

How many individuals do you wish to care for?

Do you have a gender preference?

Age Preference?

Please list any other considerations:

List 3 personal references (non-relatives):

Person 1

Name:

Address:

Phone:

Years acquainted:

Person 2

Name:

Address:

Phone:

Years acquainted:

Person 3

Name:

Address:

Phone:

Years acquainted:

We at Region V Services have an expectation of values. We also expect all members of our team to share the same values. Please tell us how you would express each value.

H.O.M.E.S. stands for: Heart, Opportunity, Morals, Education, and Support.

Heart

Heart; Family isn’t always blood. It’s the people in your life who want you in theirs; the ones who accept you for who you are. Write about what Heart means to you and how you would provide heart within Region V Services and as a subcontractor for a person living with you.

Opportuunity

Opportunity; Extended Family Homes provide choices: where to live, who to live with, and outcomes people desire to achieve. Write about what kind of Opportunities you would provide for an individual we support.

Morals

Morals; At Region V Services we strive to ensure an environment of trust. Please describe what Morals you value and how they can help to build trust within the team.

Education

Education; Tell me and I forget. Teach me and I remember. Involve me and I learn! Education is a key part of what we do here at Region V Services. Please describe a program that you would implement for someone who has behaviors of verbal aggression. What would the program recommend to do to cope with feelings, recommend alternative behaviors/actions, and how you should react when behaviors are present?

Family Study

Careers

Household Members:

Education/Experience

Employment History

Violations

Living Arrangments

List 3 personal references (non-relatives):

Person 1

Person 2

Person 3