VITAL Services : What We Do : Programs & Services : Residential Programs : Extendend Family Homes

An extended family home (EFH) creates an opportunity for people with disabilities to live in a private family home while receiving individualized care. Families must go through an extensive screening and training program before being matched with an individual who will move into their home. The EFH can be an ideal transition for individuals who have been living in a group home or independently, but now require more individualized care. The family can provide support with self-care needs, money management, medical care, and leisure/recreational activities.

Extended Family Home Application

First Name:

Last Name:

Possible Aliases:

Marital Status:

Address (Line 1):

Address (Line 2):

City:

State:

Zip Code:

Phone:

Social Security Number:

DOB:

Ethnicity:

E-mail Address:

Additional Details

Occupation/Job Title:

Current work schedule:

Job Duties:

Military History (please include branch and year(s) of service)/Type of Discharge:

Work History

Previous Employer #1:

Address:

City/State:

Phone:

Immediate Supervisor:

Occupation/Job Title:

Job Duties:

Reason for leaving:

Previous Employer #2:

Address:

City/State:

Phone:

Immediate Supervisor:

Occupation/Job Title:

Job Duties:

Reason for leaving:

Special Job Skills/Education

Education beyond high school:

Do you have any special skills/job training that would be beneficial to being an EFH Provider? If so, please list and describe why you think they would be, and how they would benefit to your job duties as an EFH:

Have you received any specialized training regarding individuals with development disabilities/intellectual functioning? If yes, please describe:

Educational considerations:

Family Dynamic

Do you currently have any children or other family members living with you? If yes, please list full name and age:

Do you have any other children not living in the home? If yes, please list full name and age:

Please describe the things your family does together:

Have you and your family traveled?

How would you incorporate your EFH into your family's every day life:

Do you have an immediate family member with a developmental disability or an intellectual functioning diagnosis?

Do you have any pets? If yes, please list name and breed:

What kind of hobbies, special interests, groups, organizations, etc., do you actively participate in?

Are you affiliated with any Church or organized religious group? If yes, which one:

Do you have any personal beliefs that may conflict or are in accord with providing services to someone with disabilities? If yes, please describe them and how this could affect the individual served:

Co-Sponsor

Full Legal Name:

Possible Aliases:

Address:

City/State:

Social Security Number:

DOB:

Ethnicity:

Phone:

Name of Employer:

Work phone number:

Address:

City/State:

Occupation/Job Title:

Current work schedule:

Job Duties:

Would the co-sponsor assist with the day to day activities and needs of the individual(s) served? If yes, co-sponsor must fill out a separate application:

Home Environment

Do you own or rent?

If renting, do you have authorization from our landlord/rental agency to have someone living with you? (Documentation required)

Name of landlord/rental agency:

Phone:

Describe the home layout (include floor plan, bedrooms, bathrooms, etc):

What community resources are available in your area?

Describe the community/neighborhood you live in:

Are there specific rules/regulation within your home that the individual would be required to follow? If yes, please describe in detail. This would include but is not limited to; smoking policy, having pets; chore responsibilities, drinking, relationships with peer, curfew, etc:

Applicant Statement

Read thoroughly before signing – ask for clarification if there is something you don’t understand.

I certify that answers given in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this “Application for Employment” as may be necessary in arriving at an employment decision. I authorize any agent of VITAL Services Inc. to contact previous employers and my personal references for the purpose of verifying any information given in this application and for references regarding my character and work history. I further authorize any agent of VITAL Services Inc. to conduct a background check through one or more of the following: I also authorize any agent of VITAL Services Inc. to access and print my Motor Vehicle Record (MVR) from the internet – upon employment, and also anytime during employment with VITAL Services Inc., in order to satisfy the insurance carrier of my satisfactory driving records.

This application for employment shall be considered active for a period of time not to exceed 60 days. (Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.)

In the event of employment by VITAL Services Inc., I understand that:

False or misleading information given in my application or interview(s) may result in discharge.

I will be required to authorize downloading a current Motor Vehicle Record at my expense.

I will be required to abide by all Policies and Procedures of VITAL Services Inc.

I will be required to satisfactorily complete all required training within time allowed.

I will be expected to stay informed of all current and revised rules, Policies and Procedures.

I will be expected to get a drug test at NE Occupational Health before orientation or training will begin

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Signature:

Date: