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Apply – Adult Foster Care Provider

Application to become an Adult Foster Care provider.

Candidates must have a high school diploma/GED, driver’s license and insurance, acceptable background check/drug screening.

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This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Type of Contract Work desired:(Required)

Adult Foster Care Provider

Relief Provider

Do you or your spouse own an automobile?(Required)

Yes

No

Do you possess a valid driver's license and insurance?(Required)

Yes

No

Are you willing to complete required training?(Required)

Yes

No

By the Kentucky Department of Developmental and Intellectual disabilities for all persons who provide direct support to individuals in the SCL Waiver program.

Have you previously been associated with LifeSkills as a contractor or employee?(Required)

Yes

No

If Yes, When and What Program?

Have you or a member of your home ever been a foster care provider with adults or children?(Required)

Yes

No

If Yes, When and What Program?

Why do you want to participate in this program?(Required)

Education and Training

Do you have a high school diploma or GED?(Required)

Yes

No

List any certificates, licenses, or special training received:

Do you know how to use a computer?(Required)

Yes

No

Do you have internet access at your home?(Required)

Yes

No

Do you have training or experience working with individuals with developmental or intellectual disabilities?(Required)

Yes

No

If Yes, please explain:

Employment and Contractor History

Please list by order of most recent employment/contract arrangement.

Employer(Required)

Supervisor(Required)

Phone(Required)

Employment Date From(Required)

Month

Day

Year

Employment Date To(Required)

Month

Day

Year

Description of Work(Required)

Reason for Leaving(Required)

Employer 2

Employer

Supervisor

Phone

Employment Date From

Month

Day

Year

Employment Date To

Month

Day

Year

Description of Work

Reason for Leaving

Residence Information

Type of Home?(Required)

House

Apartment

Mobile Home

Do you Own or Rent?(Required)

Own

Rent

Do you have homeowner's or renter's insurance?(Required)

Yes

No

Is the home accessible for persons with physical disabilities?(Required)

Yes

No

Accessible homes are a plus, but not required.

If Yes, please explain:

Number of bedrooms in home?(Required)

Number of bedrooms that are currently unoccupied?(Required)

Do you have an extra bedroom for accommodating an extra child or adult in your home?(Required)

Yes

No

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You may also contact
Arrington Richer
270-901-5000 x1228
aricher@lifeskills.com

Intellectual and Developmental Disabilities

Mission and Vision
Crisis Services for I/DD
Participant Directed Services
Vocational Services
Supports for Community Living
Adult Foster Care
Regional Programs
KEIS
I/DD Links

CAYA Collaborative Care

Come as you are.

Appointments & Non-Emergency Calls:

Bowling Green, KY
(270) 901-5999
Email: info@lifeskills.com
Fax: (270) 901-5995

Hopkinsville, KY
(270) 886-5163 or (877) 473-7766
Fax: (270) 886-5178

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Message*

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