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Search for:
Home
About Us
History
Our Team
Board of Directors
Services
At Home
At Our Centers
In Our Community
Survey Results
Press Room
News Releases
Newsletter
Annual Reports
Video Archives
Careers
Job Opportunities
Contact Us
Employee Portal
Shop
Donate
Home
About Us
History
Our Team
Board of Directors
Services
At Home
At Our Centers
In Our Community
Survey Results
Press Room
News Releases
Newsletter
Annual Reports
Video Archives
Careers
Job Opportunities
Contact Us
Employee Portal
Shop
Donate
Adult family care shared living provider application
Adult family care shared living provider application
Kevin Sprague
2022-12-12T14:45:15-05:00
Adult Family Care/Shared Living Provider Application
Applications are considered without regard to race, creed, color, religion, sex, sexual orientation, marital status, national origin, genetic information, age, and disability, military or veteran status, Vietnam Era Veteran, or being a member of the Reserves or National Guard. It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law should be subject to criminal penalties and civil liability.
Name
*
First
Last
Email
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Highest Degree Completed
How did you hear about this position?
Telephone Number
Physical Setting
Type of Housing
Own Home
Rented House
Rented Apartment
Description
(style, number of floors, exterior composition, etc.)
Number of Bedrooms
Number of Bathrooms
Handicap Accessible
Yes
No
Water Supply
Public
Private
Waste Disposal
Sewer
Septic
Description of Neighborhood
Distance to Nearest Hospital
Accessibility to Fire Department
Accessibility to services and activities
(church, grocery stores, recreating, etc.)
Number of Occupants in Bedroom 1
# Adults, # Children, Number of Beds, Remarks
Number of Occupants in Bedroom 2
# Adults, # Children, Number of Beds, Remarks
Number of Occupants in Bedroom 3
# Adults, # Children, Number of Beds, Remarks
Number of Occupants in Bedroom 4
# Adults, # Children, Number of Beds, Remarks
Sleeping accommodations for potential placement
(room size, closet, etc.):
Home Occupants
Number of adults living in the home (18 years or older):
Please list their names and their relation to you
Number of children under 18 living in the home
Number of individuals who have a permanent residence at the home, but do not stay there on a regular basis
(example: individuals attending college)
General Questions
Please describe your philosophy of services to individuals who are developmentally disabled.
Why are you interested in this position?
What are your strengths and weaknesses working with individuals that are developmentally disabled?
Describe the types of activities and interests that you would like to share with an individual.
List all volunteer or paid experiences providing in-home services or working with individuals that are developmentally disabled.
Have you been a foster parent before?
Yes
No
If yes, in what capacity? Please list the agency, the dates you provided foster care services, and describe your experience.
Have you ever applied to become a foster parent and been turned down?
Yes
No
If yes, please explain:
Do you own firearms?
Yes
No
If yes, please describe what kind, whether or not they are licensed, and how you store them.
Do you have your own transportation?
Yes
No
Can you transport an individual to meetings, school, doctor’s appointments, etc.?
Yes
No
Employment Experience
Start with your present or more recent job-you may include volunteer activities
Employer 1
Start date, End date, Supervisor (may we contact them), Job performed, Address, Reason for leaving.
Employer 2
Start date, End date, Supervisor (may we contact them), Job performed, Address, Reason for leaving.
Employer 3
Start date, End date, Supervisor (may we contact them), Job performed, Address, Reason for leaving.
References
Please list three to five references in addition to those listed as employment references. Personal or character references are acceptable if work references have been exhausted. Please do not list relatives.
Reference 1
Name, Address, Phone Number, Relationship, Years Known
Reference 2
Name, Address, Phone Number, Relationship, Years Known
Reference 3
Name, Address, Phone Number, Relationship, Years Known
Reference 4
Name, Address, Phone Number, Relationship, Years Known
Reference 5
Name, Address, Phone Number, Relationship, Years Known
Reference 6
Name, Address, Phone Number, Relationship, Years Known
Residency
Please list your places of residence for the last ten years.
Residency 1
Address, City, State, Zip, County, Length of Residency
Residency 2
Address, City, State, Zip, County, Length of Residency
Residency 3
Address, City, State, Zip, County, Length of Residency
Residency 4
Address, City, State, Zip, County, Length of Residency
Residency 5
Address, City, State, Zip, County, Length of Residency
I understand the following: It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that if hired, my employment will be at-will in nature and may be terminated, without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization. Agreement: I certify that the information on this application is true, complete, and correct. I hereby authorize the investigation of my past employment, education and activities and I release from all liability all persons, companies and corporations supplying such information. I understand false answers, statements or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.
Signature of applicant
Date
MM slash DD slash YYYY
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