COLORADO AREA HEALTH EDUCATION CENTER (AHEC) Program

HOST HOME AGREEMENT

Revised 7.23.2013

Thank you for considering the opportunity to host a health professional student. We are pleased that you would like to be a host. To ensure that students and hosts are able to share housing accommodations with reasonable expectations, University of Colorado (UC) and the Colorado Area Health Education Center (AHEC) System office request the following information from the housing hosts.

Names, social security numbers and date of birth of adults (18+) who will be present in this home at any time while the UC health professions students are residing in the home. Social security numbers and date of birth are needed in order to conduct a criminal background check. UC will cover the costs for the required criminal background checks.

Legal Name (Last Name, First Name, Initial) / Social Security Number / Date of Birth
Doe, Jonathan A. / 999-09-999 / 01/01/1962

Use other side of sheet if more than four adults will be staying in the home.

Student contact information will be provided to hosts through the regional AHEC office in your area of Colorado. If you do not receive the information within one week of being notified of a student’s impending arrival, please contact the appropriate regional AHEC Housing Liaison below:

  • Centennial AHEC: Renee Sandoval, 970.330.3608;
  • Central Colorado AHEC: Aaron Jones, 303.481.8686;
  • San Luis Valley AHEC: Lisa Lucero, 719.589.4977;
  • Southeastern Colorado AHEC: Debra Ball, 719.544.7833;
  • Southwestern Colorado AHEC: Karen Rider, 970.375.3243;
  • Western Colorado AHEC: Nicole Heil, 970.361.5558 ext. 3;

Safety for our students (and hence the host home) is a primary concern, this includes Fire and Life Safety. The UCD / AHEC require that all homes hosting students on rotation have a working smoke detector on each level of the home (minimally). Batteries are to be checked every year and the smoke detector tested according to manufacturer recommendations. Please take the time to review a “fire plan” with members of your household and share this plan with the student upon arrival at your home.

All host homes must provide a non-smoking environment.

A student must have a private bedroom with access to a bathroom that may or may not be private. The student’s bedroom must have a solid door that can be closed completely and locked. The bedroom must receive adequate heat during cool / cold temperatures as well as adequate ventilation overall, especially during warm / hot temperatures. Space heaters are not considered adequate heating (and they are considered unsafe for unsupervised or overnight use).

Students are not permitted to bring overnight guests, family members or pets.

A students’ full time job is their clinical rotation – at no time are they to be considered part of the household in terms of providing daycare, housekeeping, transportation, etc. Students are expected to clean up after themselves throughout their stay, and to give a final tidying up of their bedroom and bathroom before they leave.

Students often have irregular work hours, and access to your home 24/7 is required. They will need a key or some other means to enter your home at odd hours and potentially when you are not at home.

All households have rules. We ask that you let us know what standards you would like the student to keep while living in your home.

YES / NO / Please check all that apply:
Consumption of alcohol in the home
Washer / Dryer available in the home
Other:
Other:
Other:

Students understand they are to provide all their own toiletries, towels, bed linens and food items while they are living in your home. Please make adequate room in your refrigerator / freezer and pantry for them, unless you’d rather board them. Feel free to discuss this option with your student guest when they contact you prior to their rotation. If a student agrees to share your grocery bill, it would be the student’s responsibility to pay you directly for these costs. The Colorado AHEC System covers housing expenses only.

A Host will receive the going rate of $15.00 per night up to 112 nights. Hosts will be paid in a timely manner. If a student leaves the home before the end of the rotation, the remaining balance of the rent shall be paid by the AHEC on a prorated basis. Students do not pay additional rent to the Host. The entire amount the Host will be paid will be the responsibility of the AHEC office.

I have read and understand that I will need to provide the necessary information for the UC / Colorado AHEC System to conduct a criminal background check on all adults (18+) who will be presiding in the home during any time the student is there on rotation.

______Printed Name – Adult One

______Signature – Adult One Date

______

Printed Name – Adult Two

______Signature – Adult Two Date

______Printed Name – Adult Three

______Signature – Adult Three Date

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