Host Home Provider Application

Individual Residential Services & Supports (IRSS / Host Home)

Program Approved Service Agency (PASA) • Colorado

Thank you for your interest in becoming a Host Home Provider with Life Town Colorado. Host Home Providers open their homes and provide person-centered residential support to adults with intellectual and developmental disabilities. Our goal is to create safe, respectful, family-centered homes where individuals can build independence, relationships, and meaningful community connections.

Download the fillable PDF application

Important Applicant Notice

☐Completing this application does not guarantee selection, placement, employment, or a Host Home Provider contract.
☐Applicants must successfully complete Life Town Colorado's screening, interview, home review, reference checks, required background checks, orientation, and training requirements before providing unsupervised services.
☐QMAP (Qualified Medication Administration Personnel) and current CPR/First Aid certification are required before a provider may begin serving a person when required by the position/placement and Life Town Colorado policy. Applicants who do not already hold these credentials must complete the required classes during onboarding before final approval.
☐Host Home Provider relationships may be structured as independent-contractor or other arrangements as permitted by law and Life Town Colorado's written agreement. The final written agreement controls the relationship.

Application Checklist

☐Completed and signed Host Home Provider Application
☐Current résumé or detailed work/caregiving history
☐Three references (at least two professional preferred)
☐Valid driver's license and reliable transportation information
☐Current automobile insurance (if transporting individuals)
☐Homeowner's or renter's insurance information
☐QMAP certificate, if already completed
☐CPR/First Aid certificate, if already completed
☐Other relevant training/certifications

Life Town Colorado will provide instructions for required criminal background, Colorado Adult Protective Services (CAPS), exclusion, motor-vehicle, and other screening processes as applicable. Do not send Social Security numbers or other highly sensitive identity documents by ordinary email unless Life Town Colorado provides a secure method.

2. Host Home Experience & Motivation

Why do you want to become a Host Home Provider with Life Town Colorado?Describe your experience supporting people with intellectual/developmental disabilities, older adults, behavioral needs, mental health needs, medical needs, or other caregiving responsibilities.

4. Availability, Lifestyle & Matching

Host Home matching is person-centered. Please answer candidly so Life Town Colorado can identify compatible placements.

Current employment / schoolTypical work/school hoursRegular evening commitmentsRegular weekend commitmentsTravel frequencyCan you provide overnight support?

YesNoDepends on placement

Can you provide transportation?

YesNo

Can you support medical appointments?

YesNo

Can you support community activities?

YesNo

Experience / Comfort Areas

Area	Experienced	Willing to learn	Not a match for me
Personal care / activities of daily living (ADLs)
Medication support / administration
Behavioral support and de-escalation
Communication supports / non-speaking individuals
Mobility support / adaptive equipment
Meal planning / special diets
Diabetes or other health-related routines (with training)
Community integration and recreation
Money-management support
Appointment coordination

Matching preferences / limitations (accessibility, level of supervision, pets, smoking, transportation, behavioral/medical support, household compatibility)Languages spoken fluently, including ASL or other communication systems

5. Education, Employment & Service History

Employment / Contract History

List your most recent work, contracting, or caregiving experience. Attach a résumé if additional space is needed.

Position 1

Employer / Agency / ClientPosition / RoleDatesSupervisor / ContactPhone / EmailReason for leaving

Main duties

Position 2

Employer / Agency / ClientPosition / RoleDatesSupervisor / ContactPhone / EmailReason for leaving

Main duties

Position 3

Employer / Agency / ClientPosition / RoleDatesSupervisor / ContactPhone / EmailReason for leaving

Main duties

6. Training & Credential Requirements

Colorado PASA rules require provider agencies to maintain orientation and training sufficient for employees and contractors to perform their duties, including person-centered practices, health and safety, member-specific needs, and agency policies before unsupervised contact. Life Town Colorado will provide or identify required onboarding training.

Training / Credential	Current?	Cert Attached?
QMAP	YesNo	YesNo
CPR / First Aid	YesNo	YesNo
Crisis prevention / de-escalation	YesNo	YesNo
HIPAA / confidentiality	YesNo	YesNo
Client rights	YesNo	YesNo
Infection control / universal precautions	YesNo	YesNo
Person-centered practices	YesNo	YesNo

QMAP + CPR/FIRST AID REQUIREMENT: Applicants must hold or successfully complete Life Town Colorado-approved QMAP and CPR/First Aid training before final Host Home Provider approval/placement when required by the role and agency policy. Credentials must remain current as required.

7. Screening & Compliance Acknowledgment

Life Town Colorado is required to screen direct-care employees and contractors. Screening may include criminal background checks, reference checks, Colorado Adult Protective Services (CAPS) checks, federal exclusion checks, motor-vehicle records, and other checks required by law, payer rules, contract, or agency policy. Separate authorization forms may be required.

I am willing to complete all required background and screening processes.I understand that adults living in the proposed Host Home may also be required to complete applicable screening.I authorize Life Town Colorado to contact the references and prior employers/agencies I provide, subject to applicable law.I understand that material omissions or false statements may disqualify me or end a provider relationship.

A criminal record does not automatically mean an applicant will be rejected except where applicable law or program rules prohibit service. Life Town Colorado will evaluate screening results in accordance with governing requirements.

8. References

Provide three people who can speak to your reliability, judgment, caregiving ability, work ethic, and character. Please do not list household members.

Reference 1

NameRelationshipYears KnownPhoneEmail

Reference 2

NameRelationshipYears KnownPhoneEmail

Reference 3

NameRelationshipYears KnownPhoneEmail

9. Applicant Questions

1. What does dignity, choice, and person-centered support mean to you?2. How would you respond if the person you support makes a choice you disagree with but the choice is not immediately unsafe?3. Describe a time you stayed calm and solved a difficult caregiving, family, or work situation.4. How would you help a person become part of your household while still respecting their privacy, rights, routines, culture, and personal preferences?

10. Applicant Certification & Signature

Please read each statement carefully. By checking below, I certify and acknowledge that:

The information I provided in this application is true, complete, and accurate to the best of my knowledge.I understand that Life Town Colorado may verify information in this application and request additional documentation.I understand that I must complete all required screening, orientation, training, home-review, and credentialing steps before I may provide unsupervised services.I understand that QMAP and CPR/First Aid are required Life Town Colorado onboarding credentials for Host Home Providers as applicable to the role/placement, and I agree to complete and maintain them.I agree to protect the dignity, privacy, rights, health, safety, choices, and personal property of every individual I support.I agree to follow the person's Person-Centered Support Plan, applicable service plans/protocols, Life Town Colorado policies, and Colorado HCBS/PASA requirements.I understand that submission of this application is not a promise of placement, compensation, employment, or a contract.If selected, I will promptly report changes that could affect the safety or suitability of my home or my ability to provide services.

Applicant Printed Name *Applicant Signature (type full name) *Date *

Host Home Provider Application

Important Applicant Notice

Application Checklist

1. Applicant Information

General Eligibility

Emergency Contact

2. Host Home Experience & Motivation

3. Home & Household Profile

Household Members

Pets

Home Safety

4. Availability, Lifestyle & Matching

Experience / Comfort Areas

5. Education, Employment & Service History

Employment / Contract History

6. Training & Credential Requirements

7. Screening & Compliance Acknowledgment

8. References

9. Applicant Questions

10. Applicant Certification & Signature