SLA Provider Application – Avatar Residential

Personal Info

Name

First Last

Social Security #

Date of Birth

Address

Street Address Address Line 2 City State ZIP Code

Phone (Home)

Phone (Work)

Phone (Cell)

Email

How did you hear about shared living arrangements?

Do you have a valid driver's license?

Yes
No

Driver's License #

Do you have the minimum vehicle insurance required by the State of Rhode Island?

Yes
No

Your Residence

Do you live in a...

Do you...

Rent
Own

Do you have homeowner's / renter's insurance?

Yes
No

Do you have landlord approval to have a non-related individual move into your home?

Yes
No
Haven't asked yet

How long have you lived at your current address?

Total # of Rooms in your home?

Total # of Bedrooms in your home?

Total # of Bathrooms in your home?

Education - High School

Name of High School

Location of School

Street Address Address Line 2 City State ZIP Code

Dates Attended (From)

Dates Attended (To)

Major

Education - College

Name of College

Location of College

Street Address Address Line 2 City State ZIP Code

Dates Attended (From)

Dates Attended (To)

Major

Education - Other

Name of Other

Location of Other

Street Address Address Line 2 City State ZIP Code

Dates Attended (From)

Dates Attended (To)

Major

Character References

Please provide the following information for 3 character references (at least one character reference must not be your relative).

Name of Reference 1

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relationship

Name of Reference 2

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relationship

Name of Reference 3

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relationship

Employment

Are you currently employed?

Yes
No

What is your annual income?

Please list any additional sources of income.

Employment History

(starting with present or most recent employer)

Company 1

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

First Last

Supervisor Phone

Job Title / Description of Duties

Employment Dates (Start)

Employment Dates (End)

Why did you leave?

Company 2

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

First Last

Supervisor Phone

Job Title / Description of Duties

Employment Dates (Start)

Employment Dates (End)

Why did you leave?

Company 3

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

First Last

Supervisor Phone

Job Title / Description of Duties

Employment Dates (Start)

Employment Dates (End)

Why did you leave?

Personal

Statement

Please explain, in your own words, your reasons for wanting to share a home with a person with developmental disabilities. What changes do you anticipate that this will make in your lifestyle and that of your family? Please describe what you see as the benefits as well as the disadvantages to such an undertaking.

Characteristics

What personal qualities do you possess that you believe will assist you to be effective as a Shared Living Provider?

Experience

Please describe your experiences with individuals with developmental disabilities. This may include volunteer experiences and providing respite care.

Qualifications

Please describe any skills, qualifications and training acquired from employment and/or other experiences that may assist you to be effective as a Shared Living Provider.

Challenges

What do you foresee to be the greatest challenges involved in welcoming an adult with disabilities into your household?

Interests

What are your interests and personal hobbies?

Additional Comments

Is there any additional information about you and / or your family that you would like us to consider?

Members of Household

(please list all)

Name

First Last

Relationship

Date of Birth

Name

First Last

Relationship

Date of Birth

Name

First Last

Relationship

Date of Birth

Name

First Last

Relationship

Date of Birth

Name

First Last

Relationship

Date of Birth

Name

First Last

Relationship

Date of Birth

Do you have any frequent visitors/overnight guests?

Yes
No

Personal History

Please answer the following questions in detail. All of this information will be discussed on an individual basis during a personal interview. Please provide the name and contact information for your primary care physician. Your physician will be asked to complete a simple form providing his or her opinion on your ability to become a Shared Living Provider based on your health.

Physician's Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Describe any major medical problems for which you have had treatment in the past 10 years.

Do you drink alcoholic beverages?

Yes
No

How many drinks do you usually have in a week?

Please enter a value less than or equal to 999.

Have you or any members of your household ever been treated for, or had a drug or alcohol-related concern?

Yes
No

Please explain.

Are your currently receiving counseling or psychiatric treatment?

Yes
No

Please explain.

Do you or other members of the household smoke?

Yes
No

Do you have any pets?

Yes
No

Please list.

Have you ever been arrested?

Yes
No

Please explain.

Have you or any member of your household ever had a charge of abuse or neglect substantiated against you?

Yes
No

Please explain.

Do you have any friends or relatives who are Shared Living Providers?

Yes
No

Have you ever been, or applied to be, a Shared Living Provider or Foster Care Provider before?

Yes
No

Please explain.

Would you be willing to provide respite care, which is a temporary shorter-term living arrangement?

Yes
No

Applicant Consent

I authorize full review and verification of the information contained in this application. I release from liability any person giving or receiving information about my application. I understand that any misrepresentation or deliberate omission on this document may be justification for refusal of consideration or termination of contract. I also understand that Avatar Residential Inc. will conduct the following clearance checks:

Criminal (BCI)
Division of Motor Vehicle
Credit History
Character References
Professional References
Physician’s reference

Signature of Applicant

First Last

Date: 08/16/2017

I have read and understand the above.

Name

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