The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

22CQuTJZcCUaKTCUjUcEvGRGLu9Etd

Provider and Home Application for Full Time and Respite Homes

Thank you for your application. We will contact you soon.

Application type

* must provide value

Full Time

Respite/Part time/ Occasional

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Applicant's Name

* must provide value

City

* must provide value

WV County

* must provide value

Home Phone Number

Cell Phone Number

Business Phone

Directions to home (Please include a clear description of the outside home):

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Road condition (i.e. grave, paved, dirt)

Please provide any additional information concerning the home/neighborhood (I.e. large dog in yard, especially steep driveway, etc.)

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Do you own or rent your home?

* must provide value

Own

Rent

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Length at Address

Number of Rooms

Would a person placed in your home have his/her own bedroom?

* must provide value

Yes

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Source of Heat

Electric

Natural Gas

Propane Gas

Wood/Coal

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Source of water

Community Water

Well Water

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Length of time expected to stay in the community

Name of Applicant

* must provide value

Name of Applicant's Spouse

Race/Ethnicity

Spouse Race/Ethnicity

Religious Preference

Age

Spouse Age

Highest Grade Completed

Spouse Highest Grade Completed

Degree/Certification Received

Spouse Degree/Certification Received

Additional Training

Spouse Additional Training

Occupation/Job Title

Spouse Occupation/Job Title

Employer

Spouse Employer

Years of Service

Spouse Years of Service

Hours worked per week

Spouse hours worked per week

Shift worked

Spouse shift worked

Income Range

Spouse Income Range

Source of income other than employment

Spouse source of income other than employment

Relationship (married, cohabitating, other)

Date of marriage

M-D-Y

List any serious illnesses, operations, chronic conditions, or physical, disabilities of household members, including the name of the member.

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List any emotional or psychiatric illnesses of any household member, including the name of the member.

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List any significant substance use (past or present of alcohol, drugs or tobacco) of any household member, including the name of the member.

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Do you have reliable transportation?

* must provide value

Yes

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Are all vehicles properly licensed and insured?

* must provide value

Yes

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List names of household members who are licensed drivers

Distance to nearest hospital

Distance to nearest pharmacy

Distance to the nearest doctor's office

Distance to the nearest grocery store

Distance to the nearest park/recreation area

What is the name of your area elementary or primary school?

What is the name of your area middle or junior high school?

What is the name of your area high school?

List any convictions or civil suits (except for minor traffic violations) and the name(s) of the household member(s) involved.

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Has any household member provided services through the WVDHHR previously? If so, please list service(s) provided, dates of services, and by whom.

* must provide value

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Has any household member received services from the WVDHHR? If so, please list service(s) received, dates of services, and to whom.

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Describe any experiences you have had with individuals with physical, intellectual and/or developmental disabilities.

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What motivated you to apply to provide Specialized Family Care?

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Preferred age for an individual that may be placed in your home.

Birth to 5

6-11

12-17

Adult

Any Age

Gender

Male

Female

Either

Race/Ethnicity

Caucasion

African American

Asian American

Native American

Latin American

Pacific Islander

Multi-racial

Any Race

How did you hear about the Specialized Family Care Program?

* must provide value

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