I hereby affirm that information provided within this application, attached resume and all other supplemental information is true and complete. I acknowledge that any false or misleading representations or omissions made on said documents may disqualify me from host home provider consideration and may result in discharge even if discovered at a later date.

I understand that a host home provider agreement may be conditioned upon successfully passing a physical checkup and drug screen. Additionally, I understand that a lease or written residency agreement, criminal background review, and driving records may be obtained to satisfy host home provider requirements.

I hereby authorize persons, schools, current employers, previous employers, references, and organizations to provide Uni-Hope Life Skills and Services and/or affiliates with any requested information pertaining to my application or suitability. I release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my host home provider relationship is at-will, meaning I am free to terminate the relationship at any time and for any reason, with or without notice, and that Uni-Hope has the same right. No one has authority to enter into a contrary agreement except a written agreement signed by a Uni-Hope Life Skills and Services Officer and notarized.