Host Agency Independent Contractor Contract Forms

Document Sample
Host Agency Independent Contractor Contract Forms Powered By Docstoc
					            Host Home Provider/Independent Contractor Application Process

   1.  Agency information (brochure, flyer, fact sheet).
   2.  Application access (pick one up at Envision, download on website, mailed)
   3.  Complete application (can be brought to the office or mailed)
   4.  Agency review of application.
   5.  Agency will complete a minimum of two reference checks.
   6.  Agency makes appropriate match with potential provider and person needing
       services.
   7. Meeting/home visit/interview with potential provider.
   8. After appropriate match has been made, the agency will complete a background
       check and a motor vehicle check of potential provider.
   9. Agency will contact potential provider for payment of background check/motor
       vehicle check and for background checks on all adults (age 18 and up) living in
       the home. This charge will be $25 per person and is non-refundable.
   10. Discuss the requirement for professional liability insurance. Insurance application
       will be provided.
   11. Agency will review the requirements and responsibilities of provider.
   12. Basic training requirements for providers; obtaining certificates of trainings and
       insurance cards. Training fees will be discussed by agency.

The successful completion of the above items does not guarantee offer of contract by the
agency.
     APPLICATION TO PROVIDE HOST HOME SERVICES

NAME:__________________________________________               DATE:____________

ADDRESS:______________________________________________________________

________________________________________________________________________

TELEPHONE:_______________________ CELL PHONE:______________________

E-MAIL ADDRESS:______________________________________________________

Have you been previously employed by Envision?   Yes:______   No:______

Are you currently or have you ever contracted as a Host Home Provider for another
agency? Yes:_____ No:_____ If yes, who and when?___________________________

Have you or anyone in your household ever been convicted of a crime? Yes:___ No:___

If yes, please explain:______________________________________________________

________________________________________________________________________

How were you referred to us?________________________________________________

Why are you interested in being a Host Home Provider?___________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
EMPLOYMENT HISTORY:
Please provide all employment information for your past three employers starting with
current or most recent.

Employer:________________________________ Position held:__________________

Address:_________________________________ Telephone #:___________________

Immediate supervisor and title:_______________________________________________

Dates employed: from_____________to_____________Salary:____________________

Job summary:____________________________________________________________

Reason for leaving:________________________________________________________


Employer:________________________________ Position held:__________________

Address:_________________________________ Telephone #:___________________

Immediate supervisor and title:_______________________________________________

Dates employed: from_____________to_____________Salary:____________________

Job summary:____________________________________________________________

Reason for leaving:________________________________________________________


Employer:________________________________ Position held:__________________

Address:_________________________________ Telephone #:___________________

Immediate supervisor and title:_______________________________________________

Dates employed: from_____________to_____________Salary:____________________

Job summary:____________________________________________________________

Reason for leaving:________________________________________________________


OTHER SKILLS AND QUALIFICATIONS:_________________________________

________________________________________________________________________

________________________________________________________________________
EDUCATIONAL HISTORY:
List school name and location, years completed course of study and any degrees earned.

High school:_____________________________________________________________

College/University:_______________________________________________________

Technical training:________________________________________________________

Other:__________________________________________________________________


REFERENCES:
list three references names and telephone numbers (do not include relatives or employers)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


I hereby authorize Envision to contact, obtain, and verify the accuracy of information contained
in this request from all previous employers, educational institutions, and references. I also hereby
release from liability Envision and its representatives for seeking, gathering, and using such
information to make decisions concerning my status as an independent contractor for Envision
and all other persons or organizations for providing such information.

THIS IS NOT AN APPLICATION FOR EMPLOYMENT.

If you are retained by Envision as an Independent Contractor you will:
            • not be entitled to workers compensation benefits.
            • not be entitled to unemployment insurance benefits unless unemployment
                coverage is provided by you or some other entity.
            • be obligated to pay federal and state income tax on any moneys paid
                pursuant to the contract relationship.
            • be required to provide professional and liability insurance.

I represent and warrant that I have read and fully understand the foregoing, and that I
seek to become and independent contractor under these conditions.

Applicant signature:__________________________________                     Date:_____________
              HOUSEHOLD AND COMPATIBILITY INFORMATION

Please answer the following information as accurately as possible.

Do you own or rent?_________ How long have you lived in your home?____________

What is the square footage of the extra bedroom in your home?_____________________

What is your house style? Ranch____ 2-story____ bi-level____ tri-level____

Some other style (please describe):____________________________________________

Is your house wheelchair accessible? Yes:_____ No:_____

Could it be easily made wheelchair accessible? Yes:_____ No:_____

Please identify other household members:
NAME:                                          AGE:           RELATIONSHIP:

_______________________________                ________       ________________________

_______________________________                ________       ________________________

_______________________________                ________       ________________________

_______________________________                ________       ________________________

_______________________________                ________       ________________________

_______________________________                ________       ________________________



Please circle all characteristics that you feel would be a good match for your household:

smoker         non-smoker        enjoys children      likes animals           male

female         under 30 years           30-60 years      over 60 years        blind

downs syndrome         cerebral palsy          seizure disorder       hearing impaired

autism         behavioral concerns             uses wheelchair        adaptive equipment


Please list hobbies, interests and activities you and your household like to participate in:

________________________________________________________________________

________________________________________________________________________

				
DOCUMENT INFO
Description: Host Agency Independent Contractor Contract Forms document sample