Volunteer Information

Shared Living Provider Application

* Required Fields

Profile Information

First Name

Last Name

Address

Address 2

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Work Phone

Date of Birth
(mm/dd/yyyy)

Social Security Number

I am applying for

Marital Status

Number of Years Married

Gender Preference

I would prefer persons between the ages of:

Other Members of My Household (Name, Age, Relationship)

What Languages are Spoken in the Home?

Do you own any pets?

If yes, what are they?

If no, do you mind pets?

If the individual has a pet, can it be brought to your home?

Home and Experience

Do you rent or own?

Total number of rooms

Total Number of Bedrooms

If house is multi-leveled, is there a bedroom on the ground floor?

Is there a bathroom on the ground floor?

Is your home handicapped accesible?

How many insured vehicles do you have at your home?

Have you ever been employed by Venture?

If yes, indicate positions held

Are you currently a shared living or foster care provider contracted with another agency?

If yes, with what agency and for how long?

Have you ever been a care provider with another agency?

If yes, what agency, how long were you a provider and describe the experience.

Do you have a valid drivers license?

If yes, what state(s)?

Are you willing to complete a Registry of Motor Vehicle Driving Record?

Why are you interested in becoming a shared living provider?

Please summarize your skills and experience (paid an/or volunteer) that you posses relating to the field of intellectual and developmental disabilities.

How do you think it will change your lifestyle?

What concerns do you have regarding becoming a provider?

Describe your support system that would be available if you were to become a provider?

Do you currently work?

If yes, what is your typical schedule?

What do you see as your role and responsibilities if you become a provider?

How long of a commitment are you willing to make?

Agreement

I authorize investigation of all statements on this application as is necessary in arriving at a contracting decision. I understand that misrepresentation or omission of facts is cause for immediate termination of any contractual agreement. Further, I consent to a CORI (Criminal Offender Record Information) investigation as part of the application process and authorize the CORI Coordinator to conduct further CORI investigations during the course of the contract. By checking this box, I authorize the submittal of this application.