Starting with present or most recent employer, please account for all employment.
Please answer the following questions in detail. All of this information will be discussed on an individual basis during the 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 physical health.
You may have a job outside the home, but you will have specific obligations as a home provider, as stated in a contract between you and AccessPoint RI. You will have the opportunity to review the contract prior to making any decision.
Thank you for taking the time to fill out this application completely. Please read the important statement below, then sign and date this form.
I authorize full review and verification of my experience/education as well as verification of any and all information provided by me or any member of my household for purposes of advancing to the next step in the process of becoming a Shared Living Home Provider with AccessPoint RI. I release from liability any person giving or receiving such information. Any material misrepresentation or deliberate omission of a fact on this request for consideration may be justification for refusal of, or if contracted with, termination of said contract. I understand that AccessPoint RI will conduct the following clearance checks on all members of my household who are over the age of 18:
I have read and understand the above.