Respite Provider Application

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We would love to hear from you! We appreciate your inquiry and will be in touch shortly.

Date
MM slash DD slash YYYY
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone: (Home)
Phone: (Work)
Phone: (Cell)
Birth Date
MM slash DD slash YYYY
Last 6 Digits of Your Social Security Number
Current Occupation
Hours Per Week
Educational Background
High School
College
Additional Education
Current Certifications: (CPR, First Aid, Sign Language, etc.)
Special Skills/ Qualities that you would feel contribute to providing respite care:
Experience with developmental disabilities:
Other professional/Volunteer experience:
Do you have any experience caring for disabled adults with medical conditions? (Please describe)
Do you have any physical limitations? Are you presently under the care of a physician for treatment of a condition that would prevent you from caring for a cognitively or physically disabled adult?
If the person will be spending any time in your home, please provide the following information:

Person 1:
Name
First Last
Age
Relationship to you
Time regularly spent outside of home
Person 2:
Name
First Last
Age
Relationship to you
Time regularly spent outside of home
Person 3:
Name
First Last
Age
Relationship to you
Time regularly spent outside of home
Descriptions of Home: (Number of stairs to enter the home, number of bedrooms, location of available bedroom, composition of home, number of bathrooms; etc.)
I agree to a home study evaluation, which includes an inspection and photos of my home, to determine my eligibility to provide shared living respite services.
Signed: (Type Name)
Date
MM slash DD slash YYYY
General Questions:
Do you live in (check one):
- Own Home
- Rented Home
- Apartment
Do you have any pets?
- Yes
- No
Please list type and age of pets:
Number of smokers in the home:
Is smoking acceptable:
Do you or any member of your household have current or past problems with the use of alcohol or dugs? Please explain:
Do you or any member of your household have current or past emotional problems? Please explain
How do the other household members feel about having another person share their home?
Do you have a valid driver's licesnse?
Do you own a car?
Please list the nearest hospital:
References:

Please provide names and occupations of at least three people; 2 not related to you and 1 who has supervised your work, as references to be contacted.

Reference 1:
Name
First Last
Relationship
Phone
Reference 2:
Name
First Last
Relationship
Phone
Reference 3:
Name
First Last
Relationship
Phone
I certify that all information on this Shared Living respite application about my home and myself is ture and complete to the best of my knowledge. I understand that the Director or designee may check the information and references for the screening process. I release Riverside Community Care and its representatives from liability for seeking such information and other persons for furnishing such information. I understand that this document does not constitute a contract. Any false or misleading information given here may result in cancellation of a contract. No statements during the interview or home study shall me contained in the respite contract agreement.
Signature (type name):
Date
MM slash DD slash YYYY
If you decide to download this application (and not submit it online), please email the completed application to: sharedliving@riversidecc.org or fax to: 781-762-9094, or mail to: Riverside Shared Living, 595 Pleasant Street, Norwood, MA 02062

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Educational Background

If the person will be spending any time in your home, please provide the following information:

Person 1:

Person 2:

Person 3:

I agree to a home study evaluation, which includes an inspection and photos of my home, to determine my eligibility to provide shared living respite services.

General Questions:

References:

Please provide names and occupations of at least three people; 2 not related to you and 1 who has supervised your work, as references to be contacted.

Reference 1:

Reference 2:

Reference 3: