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shared living application detailed
Shared Living Program Application
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My Preference would be to work with the following:
Shared Living (Long-Term)
Respite (Short-Term)
Please select all that apply.
Have you previously applied to be a Merakey Shared Living Provider
Yes
No
When did you apply?
Is your home currently licensed under any program?
Yes
No
Foster care, Day care, Domiciliary care, Personal care home, Life sharing?
Have you lived outside of the current state you reside within the last 7 years?
Yes
No
Do you rent or own?
Rent
Own
Do you carry renter/homeowner insurance?
Yes
No
Do other people reside in your home?
Yes
No
Residents
Name
Relationship
Age
Gender
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Please include all people regardless of age.
Are you employed?
Yes
No
Name of Employer
Employer Address
Current work hours/schedule
Current regulation requires completion of the following:
Physical/ TB for entire household
PA/FBI/Child Abuse background checks for entire household
Annual Training
Will there be any barriers to completing?
Yes
No
Please Explain
How did you learn about Shared Living opportunities with Merakey?
Facebook/Instagram
Indeed
School / Agency
Merakey Staff
Other
Please explain how you learned about Shared Living
Explain why you want to be a Merakey Shared Living provider
Please include your previous experience of assisting a person(s) with disabilities.
Please identify an individual other than yourself who would most likely be available to provide short term respite care for the person you are supporting.
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Relationship
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