ADH/CDH Applicant Questionnaire Step 1 of 2 50% Date:* MM slash DD slash YYYY Name:* First Middle Last Email:* Enter Email Confirm Email Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Nearest (major) Cross Streets: Phone:*Days/Hours Available for Screening: 1. How did you hear about our Agency?* Current GAC Provider Family Friend Advertisement Internet Job Fair Other Event 2. Are you interested in becoming a licensed ADH (Adult Development Home) for adults, or CDH (Child Developmental Home) for children?* ADH CDH 3. Do you have a current Arizona Driver’s License, Arizona ID Card, U.S Passport (optional), or a Social Security Card?* Yes No 4. Do you have, or can you obtain a First-Class Fingerprint Clearance Card and are at least 21 years of age?*(this means you have no arrests, no convictions, and are not currently awaiting trial) Yes No 5. Do you have a reliable vehicle available to you?* Yes No 6. Have you ever provided services through another Agency?* Yes No 7. Do you currently work outside the home?* Yes No If yes, what are your current work hours?* 8. Do you currently have a computer, fax, or scanner?*(Check all that apply) Computer Fax Scanner None 9. If you do not have or own a computer, fax, or scanner, are you willing to obtain one in order to become an ADH/CDH Provider?*(Please note that these items are required to become an ADH/CDH Provider) Yes No 10. Are you open to having a placement in your home that practices a religious belief other than your own?* Yes No 11. Are you open to assisting your placement in celebrating religious/secular holidays?* Yes No 12. Are you open to assisting your placement in attending religious events such as church sessions, social events, etc.?* Yes No 13. Are you open to taking a placement that is of a nationality, race, or culture other than your own?* Yes No 14. What languages are primarily spoken in your home?*(Check all that applies) English Spanish Other 15. If Dial-A-Ride/public transportation is not available to your placement at any certain time, are you able to transport your placement to doctors’ appointments, day programs, social events, etc.?* Yes No 16. Please list all persons living in your home. If they are over 18 years of age, can they obtain a Fingerprint Clearance Card?Name:* First Last Age:* Relationship:* Obtain a Fingerprint Clearance Card?* Yes No N/A Name: First Last Age: Relationship: Obtain a Fingerprint Clearance Card? Yes No N/A Name: First Last Age: Relationship: Obtain a Fingerprint Clearance Card? Yes No N/A Name: First Last Age: Relationship: Obtain a Fingerprint Clearance Card? Yes No N/A Name: First Last Age: Relationship: Obtain a Fingerprint Clearance Card? Yes No N/A
