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APPLICANT NOTE: This application form is intended for use in evaluating your qualifications to be an Independent Host Home Provider. This is not an employment contract. Please answer all questiosn completely and accuratey. False or misleading statements during the interview and on this forms are grounds for terminating the inquiry process or, if discovered after executing a contract, terminating the contract. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, color, age, creed, national origin, sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A felony convictio will not necessarily bar an aplicant from consideration. Additional testing of job-related skills and for the presence of drugs in your body may be required to executuion of a contract. 

Host Home Provider Application

Job Type: Contractor

Who Are We?

At Empowered Care, we believe that everyone deserves the opportunity to live a fulfilling and independent life. We are dedicated to supporting individuals with developmental disabilities by providing personalized care in a home setting. Our mission is to create a welcoming environment where individuals can grow, connect with their communities, and achieve their personal goals. As a Host Home Provider, you become a vital part of this mission—offering not just a place to live, but a place to belong.

Who Are You?

You are compassionate, patient, and driven by the desire to make a difference. You have a home that you’re willing to open to an individual in need, and a heart that’s ready to support them in their journey to independence. You may be an experienced caregiver, a retiree looking for a meaningful way to give back, or someone who simply believes in the power of inclusion and support. No matter your background, if you’re ready to make a lasting impact, you belong here.

Who Are You?

As a Host Home Provider, you will welcome an individual with developmental disabilities into your home and provide the support, encouragement, and stability they need to thrive. Your role is about more than just caregiving—it’s about creating a family-like environment where they feel safe and valued. You’ll:

  • Help build independence by assisting with daily activities like cooking, budgeting, and personal care.

  • Foster connection by encouraging social outings, community involvement, and meaningful relationships.

  • Be a mentor and advocate, guiding them toward their personal goals and celebrating their achievements.

  • Ensure well-being by coordinating healthcare appointments, medication, and daily routines.

  • Receive ongoing support and training from Empowered Care, ensuring you feel confident in your role.

Any traffic violations?
Yes
No
Do you have a weapon in your home?
Yes
No
If so is it registered?
Yes
No
Do you have a pool or sauna?
Yes
No
Do you have experience working with people with disabilities?
Yes
No
Which service would you like to provide?
Host Home Provider
Respite Provider

Please provide information about the individuals currently living in your home who may be there while you are a Host Home/ Respite provider:

All individuals over the age of 18 will need CAPS, CBI background checks prior to Person Receiving Services moves in.

Do you or any members of your household have a communicable disease?
Yes
No
Have you ever worked for Empowered Care LLC before?
Yes
No
Have you ever applied for a foster care license?
Yes
No
Were you denied?
Yes
No
Are you currently licensed to provide day care in your home?
Yes
No

Education, Training and Special Skills

Do you have any special certifications in related fields?
Yes
No
Are you proficient in sign language?
Yes
No

Employment History

More Details

Please mark answers for the appropriate setting for your home
Is your home wheelchair accessible?
Yes
No
Is any person currently living in your home receiving services from this or any other human service agency?
Yes
No
I prefer to work with the following age group and people:
I think I can accommodate an individual who:
Do you have any young children who frequently visit your home?
Yes
No
Please mark activities you frequently participate in or would be interested in sharing with individuals

Please provide information for TWO- Non relatives who you know well:

Name, full address, length of time at residence, home/ work phone

Name, full address, length of time at residence, home/ work phone

Certification and Release

I certify that I have read and understand he applicant note above and that the answers given by me to the foregoing questions and to the statements made by me are complete and true to the best to my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejections of my application or termination of contract at an time during the terms of the contract. I authorize the company an/ or its agents including individual reporting bureaus, to verify any of this information. I authorize all former employers, persons, school, companies and law enforcement authorities to release any information concerning my background and hereby release any said person, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during the contract period.

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