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Respite Provider Application

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  • Educational Background

  • If the person will be spending any time in your home, please provide the following information:

    Person 1:

  • Person 2:

  • Person 3:

  • I agree to a home study evaluation, which includes an inspection and photos of my home, to determine my eligibility to provide shared living respite services.

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  • General Questions:

  • References:

    Please provide names and occupations of at least three people; 2 not related to you and 1 who has supervised your work, as references to be contacted.

    Reference 1:

  • Reference 2:

  • Reference 3:

  • I certify that all information on this Shared Living respite application about my home and myself is ture and complete to the best of my knowledge. I understand that the Director or designee may check the information and references for the screening process. I release Riverside Community Care and its representatives from liability for seeking such information and other persons for furnishing such information. I understand that this document does not constitute a contract. Any false or misleading information given here may result in cancellation of a contract. No statements during the interview or home study shall me contained in the respite contract agreement.

  • Date Format: MM slash DD slash YYYY

  • If you decide to download this application (and not submit it online), please email the completed application to: or fax to: 781-762-9094, or mail to: Riverside Shared Living, 595 Pleasant Street, Norwood, MA 02062