Registry Provider Application

Thank you for your interest in the Connecting Point Registry.

The Registry is a collection of independent care providers who are available for referral to IHSS consumers. Referrals are based on each consumer’s needs, schedule, and preferences. The current rate of pay is $15.50 per hour.

Your answers on this application will give us a better understanding of your experience, preferences, and schedule so that we may match you appropriately. Please answer each question thoroughly.

How did you hear about us?
Personal Information
Name*
First Last
Social Security Number*
Home Phone
Cell Phone
Email
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Physical Address
Street Address Address Line 2 City State ZIP Code

If different from above.
Availability
Total number of hours available each week*
Please enter the times you are available each day of the week.*
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Example: 10 am-3 pm
About You
Are you 18 years of age or over?*
- Yes
- No
Do you smoke?*
- Yes
- No
What form of transportation will you use to get to work?*
- Bus
- Car
- Walk
Are you willing to use your car to run errands?
- Yes
- No
Would you like to be referred to private pay consumers?*
- Yes
- No
Are you fluent in any languages other than English? If yes, please list them here:
Will you work for a smoker?*
- Yes
- No
Are you looking for a live-in position?*
- Yes
- No
What is your gender identity?*

For example: Female, Male, Transgender Female, Nonbinary, etc.
Do you have a gender preference of the person you work for?*
- Male
- Female
- No preference
Are you willing to drive a consumer's car to run errands, etc.?*
- Yes
- No
Will you work for a consumer with pets?*
- Yes
- No
Are you willing to work on short-notice during a local emergency or disaster?*
- Yes
- No
Which county are you interested in working in?*
- Nevada County
- Plumas County
- Sierra County
Please mark which locations you are willing to work in.*
- Select All
- Cedar Ridge
- Chicago Park
- Floriston
- Grass Valley
- Nevada City
- North San Juan
- Penn Valley
- Rough & Ready
- Lake of the Pines
- Smartsville
- Truckee
- Washington
Please mark which locations you are willing to work in.*
- Select All
- Belden
- Canyon Dam
- Chester
- Chilcoot
- Clio
- Crescent Mills
- Cromberg
- East Quincy
- Graeagle
- Johnsville
- Lake Almanor
- Meadow Valley
- Mohawk
- Paxton
- Portola
- Quincy
- Spring Garden
- Taylorsville
- Vinton
Please mark which locations you are willing to work in.*
- Select All
- Calpine
- Downieville
- Loyalton
- Sierraville
- Sierra City
Please mark which types of work you are willing to do.*
- Select All
- Accompaniment to Medical Resources
- Ambulation (assist with walking, sitting, etc.)
- Bathing, oral hygiene, grooming
- Bowel & bladder care (full care)
- Bowel & bladder care (minimal assistance)
- Care & assistance with prosthesis
- Consumer uses oxygen
- Domestic services (basic housecleaning)
- Dressing
- Feeding (cutting food, prompting, assisting)
- Heavy cleaning (authorized by IHSS social worker)
- Meal clean up (dishes, wiping counters, etc.)
- Menstrual care (changing pads, etc.)
- Moving in & out of bed
- Other shopping & errands
- Paramedical services (assisting w/bandages, etc.)
- Preparation of meals
- Protective supervision (for someone who can’t be left alone)
- Respiration (assisting w/breathing treatments, etc.)
- Routine bed baths
- Routine laundry
- Rubbing skin, repositioning, etc.
- Shopping for food
Education, Training, & Experience
If you have a resume, please attach it here.
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 256 MB.
Please list any applicable education or training you have completed.
Degree or Course Date Completed

Use one line per degree or course. Click the + button to add an additional line.
Please list any applicable work experience (or attach resume above).*
Company Name Duties Performed Start Date End Date

Use one line per job. Click the + button to add an additional line.
Please list any current licenses or certificates you hold.
License or Certification Expiration Date

Use one line per license or certificate. Click the + button to add an additional line.
Upload Licenses or Certificates
Drop files here or

Max. file size: 256 MB.
Only licenses or certificates uploaded here will be considered.
Please tell us why you are interested in providing in-home care.*
References
Please list two work references and one personal reference. DO NOT USE FAMILY MEMBERS.
Work Reference 1*
Reference Name Phone Number Relationship to Applicant Company Name Start Date End Date
Work Reference 2*
Reference Name Phone Number Relationship to Applicant Company Name Start Date End Date
Personal Reference*
Reference Name Phone Number Relationship to Applicant Length of Time Known
Background Check
Please list all of the counties you have lived in within the last 10 years.*
County State Dates of Residence

Use one line per county. Click the + button to add an additional line.
Have you ever been convicted of a felony or misdemeanor charge?*
- Yes
- No
Please answer the question honestly. A “Yes” answer will not automatically disqualify you from the Registry. Failure to disclose this information will automatically disqualify you from the Registry.
Have you been convicted of a crime in the last 10 years?*
- Yes
- No
Please answer the question honestly. A “Yes” answer will not automatically disqualify you from the Registry. Failure to disclose this information will automatically disqualify you from the Registry.
Please list any crimes you have been convicted of in the last 10 years.*
Date of Offense Offense Sentence Release Date
Are you currently or have you ever been on probation?*
- Yes
- No
Please answer the question honestly. A “Yes” answer will not automatically disqualify you from the Registry. Failure to disclose this information will automatically disqualify you from the Registry.
Please tell us how you heard about Connecting Point.*
- Select All
- CalWORKs/EDD
- Church
- Connecting Point website
- Craigslist
- Facebook
- Flyer
- FREED
- IHSS Social Worker
- Newspaper
- Presentation
- Provider union
- Training
- Walk-in
- Word of Mouth
Certification of Information*
I certify under penalty of perjury that all information on this form is true and correct to the best of my knowledge. I understand that any omission or misrepresentation of information on this form may disqualify me from being listed on the Registry. I give Connecting Point permission to share relevant information in my file with individual consumers who are looking for providers. I understand that any false information may eliminate me from eligibility for participation on the Connecting Point Registry.
Signature*
First Last
Please enter your name here to act as your signature.
Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

Degree or Course	Date Completed

Company Name	Duties Performed	Start Date	End Date

License or Certification	Expiration Date

Personal Information

Availability

About You

Education, Training, & Experience

References

Background Check