Supported Roommate Application

Our commitment is to promote the development and well being of individuals, to strengthen positive relationships between individuals and their communities, and to promote independent living.

Supported Roommate Application

Eligibility

Work Schedule

Extra Placement Information

If This Position Is Not Available Would You Consider Other Openings?

Placement/Subcontract Desired

Education - Highschool

Education - College/University

Education - Business or Trade School

Education - Professional School

Certification/Training

First Aid - Current

First Aid - Current

Medication Administration - Current

CPI - Current

Positive Practices - Current

Abuse Reporting / Prevention Protocols - Current

References

PLEASE LIST TWO REFERENCES OTHER THAN RELATIVES

Can We Contact Your Current Employer

How Did You Hear About Join Our Team?

Home, Location and Types of Services

IN THE SPACE BELOW, PLEASE PROVIDE INFORMATION ON YOUR HOME, LOCATION, AND THE TYPES OF SERVICES YOU ARE ABLE TO PROVIDE. Are There Others Living In The Home?

Description of The Home and Neighborhood

What Types Of Supports Are You Willing To Provide (Check Those That Apply)

Resume

Application Form and Consent

PLEASE READ CAREFULLY APPLICATION FORM AND CONSENT As indication that you have read and understood each sentence, please write your initials in the spaces provided.

I certify that all answers given and statements made in this Application are true and complete to the best of my knowledge. *

I acknowledge and agree that no promises regarding contracts or subcontracts have been made to me and I understand that nothing in this application form, or in the granting of any interview creates a work-related or position-related contract or provides any benefits to me. *

In the event of any work or subcontract offers, I understand that I am required to abide by all policies, rules and regulations set forth by the Agency. I also understand that the agency may revise policies, rules and regulations, in whole or in part at any time. *

VERIFICATION *

(780) 702-1733

Services

Employment