Where Compassion Becomes Your Career

Step into a workplace that values empathy, teamwork, and personal growth. At Compassionate Comfort Care, your dedication makes a difference every day. Build a rewarding career while supporting individuals, strengthening families, and creating meaningful moments that truly matter.

Personal Information

Full Name

First Name Last Name

Address

Street Address State / Province / Region ZIP / Postal Code

Home phone

Work phone

Cellphone

Education

High School Name

City & State

Year Graduate

College

City & State

Year Graduate

Diploma

Additional Qualifications

Work History

Employer

Address

Street Address

Dates Of Employment

Job Title/ responsibilities

Reason For Leaving

Phone

Address

City State / Province / Region

Supervisor

May we contact this person?

Employer

Address

Street Address

Dates Of Employment

Job Title/ responsibilities

Reason For Leaving

Phone

Address

City State / Province / Region

Supervisor

May we contact this person?

Employer

Address

Street Address

Dates Of Employment

Job Title/ responsibilities

Reason For Leaving

Phone

Address

City State / Province / Region

Supervisor

May we contact this person?

Please provide the names of three(3) persons who have knowledge of your work experience (Professionals, Instructors, Business Partners, Clients).

Name

Cell phone

Job Title

Home phone

Years known

Name

Cell phone

Job Title

Home phone

Years known

Name

Cell phone

Job Title

Home phone

Years known

Job Specific Information

Why do you feel that you can be a good HHP?

Stability and consistency are very important to our residents. Please list some reasons why we could count on you for at least a year:

Please list other obligations (i.e jobs, family commitments) you plan to continue during your contract?

Why do you think your lifestyle would be conducive to a Host Home environment?

Host Home Provision is an around-the-clock endeavor. Please list your plan to get necessary respite, time off and how you will be "taking care of yourself."

What persons other than you and the person in services will be residing in the home?

Have you ever been investigated for a M.A.N.E allegation?

Have you ever been convicted of a crime? If Yes, please explain the crime in full. Include an explanation for the final outcome. We do conduct criminals background checks.

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT FALSIFICATION OF INFORMATION COULD LEAD TO TERMINATION, AND I RELEASE THE AGENCY, REFERENCES, AND PREVIOUS EMPLOYERS FROM LIABILITY IN REGARD TO THIS APPLICATION. I ALSO AUTHORIZE COMPASSIONATE COMFORT CARE TO RUN BACKGROUND CHECKS, VERIFY COLLEGE DEGREES, CONTACT REFERENCES, AND OBTAIN OTHER INFORMATION PERTAINING TO THIS APPLICATION. FURTHER, I UNDERSTAND THAT ANYONE WHO WILL BE DOING BACKUP IS SUBJECT TO COMPASSIONATE COMFORT CARE RULES AND STATE REGULATIONS REGARDING HIRING AND TRAINING; FAILURE OF BACKUP PROVIDERS TO MEET OUR STANDARDS COULD DISQUALIFY THEM FROM PROVIDING SERVICES.

Signature

Max. file size: 256 MB.

Date

In order to help us determine the compatibility of potential Host Home Providers and people we serve, please answer the following questions so that we can learn more about you and your home.

Name

Phone

Address

Street Address

County

How do you heard about us

1. Please provide your experience working with people with intellectual and/ or developmental disabilities.

2. Why are you interested in living with a person with intellectual and/ or developmental disabilities.

3. Please describe your typical daily routine (e.g). 7am- Wake-up; 9am-Kids to school; 6pm-Dinner time ,etc.)

4. What are your expectations from having a person with disability living in your home?

5. Is there anything you are uncomfortable doing?

6. Do you have any limitations on transportation or availability? (e.g. Day Program, social events, personal preferred activities, etc.)

7. Do you have another job? If so, what is it and what is your typical schedule/ hours?

8. What do you consider to be your strengths and weaknesses?

9. Please list your interests/ Hobbies.

10. How many people live in your home? Please include any individuals in services currently in your home. (Name, Relationship to you, Age)

(Anyone over the age og 18 that lives in your home will need to fill out a background check form)

Do you have any pets?

Yes

If Yes, what kind?

Do you have CPR/ First Aid, Medication Administration, safety care or any other training required to be a provider?

Home Setting

Please describe your home

Is there an available Bedroom and Bathroom on the main floor?

Yes

Is your home wheelchair accessible?

Yes

Are there any steps to get into your home?

Yes

If Yes, How many?

If Yes, could be a ramp be installed?

Yes

Are there stairs inside your home?

Yes

If Yes, could be a ramp be installed?

How many extra bedrooms?

How many bathrooms

Describe your kitchen

Describe your laundry room

What is the yard like?

Does your home have fire extinguishers, smoke detectors, and CO2 detectors?

Yes

Do you ________? If you rent your own home, when is your lease up?

Rent

Own your home

when

Do you have homeowner's insurance?

Yes

If not, you will need to get it. We will need a copy of it.

Max. file size: 256 MB.

Please indicate how you access the community:

Do you own a car?

Yes

If yes, please list the primary vehicle used for transporting yourself and the people in your home: (Make, Model, Year).

Do you have auto insurance?

Yes

If yes, please provide a copy of the policy. If not, you will need to get it.

Max. file size: 256 MB.

How close to public transportation are you?

What bus lines are close to your home?

Please provide a description of what types of community resources are within a 5-mile radius of your home. (Malls, stores, movie theaters, churches, recreational facilities, etc.)

What are you looking for in the person who would live in your home!

Age

Skill Level

Abilities

Personality

Sex

Other

1. Would you consider a person with physical or behavioral challenges? Please explain:

2. What is your desired monthly compensation level?

How do you prefer to be contacted? (if you don't have a preference, check all that apply)

E-Mail

Cell Phone

Home Phone

4. Do you have a working computer that you are comfortable using? (You will need to be available via both e-mail and phone as you will be contacted frequently and sends/receives documents easiest through e-mail)

5. Do you have any questions or additional comments?

MOTOR VEHICLE AND CRIMINAL HISTORY CHECK

(Please present Driver's license and Social Security Card upon submital)

Name

First name Middle Last name

Home phone

Work phone

Other name used

Last date used

Address

Street Address State / Province / Region ZIP / Postal Code

Cell phone

SSN

Sex

Male

Female

DOB

Driver's license #

Last addresses for the last 7 years: (List addresses beginning with the most recent.)

1. Street, City, County, State, zip, years: From- To

2. Street, City, County, State, zip, years: From- To

3. Street, City, County, State, zip, years: From- To

4. Street, City, County, State, zip, years: From- To

5. Street, City, County, State, zip, years: From- To

6. Street, City, County, State, zip, years: From- To

7. Street, City, County, State, zip, years: From- To

AUTHORIZATION TO RELEASE INFORMATION AND RECORDS

understand that COMPASSIONATE COMFORT CARE will use information, to obtain one or more consumer reports and/or investigative consumer reports ("Report") as part of the hiring or acceptance process. I also understand that if hired or accepted, to the extent permitted by law, COMPASSIONATE COMFORT CARE may obtain further Reports so as to update, renew or extend my employment or contract. I authorize all persons who may have information relevant to this investigation to disclose it to Esther House and/or their agent. I release and agree to hold harmless all persons providing such information to COMPASSIONATE COMFORT CARE, its officers, directors, employees and agents from liability on account of such disclosure. I also release and discharge COMPASSIONATE COMFORT CARE and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original. I understand COMPASSIONATE COMFORT CARE investigation may include obtaining information regarding my credit background, bankruptcies, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support, accounts placed for collection, character, general reputation, personal characteristics and standard of living, driving record and criminal record, subject to any limitations imposed by applicable federal and state law. I understand such information may be obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such information may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or with others whom I am acquainted. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release to COMPASSIONATE COMFORT CARE, the following information and/or copies of documents from my military service record: 00214, service record, and any disciplinary records.

I understand if COMPASSIONATE COMFORT CARE makes a conditional decision to disqualify me based on all or in part on my Report, I must be notified by COMPASSIONATE COMFORT CARE seven business days of their receipt of the Report. I hereby consent to this investigation and authorize COMPASSIONATE COMFORT CARE to proceed to my background. In order to verify my identity for the purposes of Report preparation, I am voluntarily releasing my date of birth, social security number and the other information and fully understand that all employment decisions are based on legitimate non- discriminatory reasons. Additionally, I make this authorization to be valid for as long as I am an applicant, employee, or contractor with COMPASSIONATE COMFORT CARE.

The name, address and telephone number of the consumer reporting agency designated to handle inquiries regarding the investigative consumer report is: ADP | 301 Remington Street, Fort Collins, CO, 80524, and can be reached by phone at 800-367-5933 or online at

By signing below, I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, and any related state summary of rights.

Applicant Signature

Date

FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION

As an applicant for employment, Independent Contractor or a current employee of COMPASSIONATE COMFORT CARE you are a consumer with rights under the Fair Credit Reporting Act. When any of the following circumstances exist, COMPASSIONATE COMFORT CARE may choose to obtain and use information contained in either a consumer report and/or investigative consumer report from a consumer reporting agency about you: (1) when considering your application for employment, (2) when making a decision whether to offer you a contract or employment (if you are hired), (3) when deciding whether to continue your Independent Contract or continue your employment (if you are hired), or (4) when making other contract-related or employment-related decisions directly affecting you.

For explanation purposes, a "consumer reporting agency" is a person or business which, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing consumer reports for others, such as COMPASSIONATE COMFORT CARE.

A "consumer report" means any written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment or contract purposes.

An "Investigative consumer report" means a consumer report or portion thereof in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, associates or others with whom you are acquainted or who may have knowledge concerning any such items of information.

An Investigative consumer report may be requested by the employer. You may request, in writing within a reasonable time, additional disclosures regarding the nature and scope of the investigation requested as well as a written summary of your rights under the Fair Credit Reporting Act.

By signing below, I,

hereby voluntarily authorize COMPASSIONATE COMFORT CARE to obtain either a consumer report or an investigative consumer report about me from a consumer reporting agency and to consider this information when making decisions regarding my contract eligibility or employment at COMPASSIONATE COMFORT CARE. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above.

Name

Date

With constant flow of personal, confidential information pertaining to the people receiving services at TOPCARE SOLUTIONS. This information needs to be passed to providers so that they can be better equipped to serve that individual. With this knowledge, we have a great responsibility to respect and maintain confidentiality about these personal matters.

Information should be shared only with people who are directly involved with the person receiving services. This includes the Interdisciplinary Team, health care professionals, and the day program employees serving this person. To share the information with others may violate confidentiality.

People with developmental disabilities may not have the skill or intellectual capacity to defend themselves if they do not agree with or believe what is said about them. so please be sensitive to anything that can undermine hard-earned dignity for the people receiving services at COMPASSIONATE COMFORT CARE.

I have read, understand, and have had any questions regarding the above information answered.

Signature

Date

Careers

Where Compassion Becomes Your Career

Personal Information

Education

Work History

Please provide the names of three(3) persons who have knowledge of your work experience (Professionals, Instructors, Business Partners, Clients).

Job Specific Information

In order to help us determine the compatibility of potential Host Home Providers and people we serve, please answer the following questions so that we can learn more about you and your home.

(Anyone over the age og 18 that lives in your home will need to fill out a background check form)

Home Setting

What are you looking for in the person who would live in your home!

MOTOR VEHICLE AND CRIMINAL HISTORY CHECK

Last addresses for the last 7 years: (List addresses beginning with the most recent.)

AUTHORIZATION TO RELEASE INFORMATION AND RECORDS

FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION

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