Registry Provider Application - Plumas

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 $18.50 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.

Provider Application

Name(Required)

Social Security Number(Required)

Birthdate(Required)

Home Phone(Required)

Work Phone

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Availability

Monday

(SELECT ALL THAT APPLY)

Tuesday

(SELECT ALL THAT APPLY)

Wednesday

(SELECT ALL THAT APPLY)

Thursday

(SELECT ALL THAT APPLY)

Friday

(SELECT ALL THAT APPLY)

Saturday

(SELECT ALL THAT APPLY)

Sunday

(SELECT ALL THAT APPLY)

Total Number of Hours Available Each Week

Personal Information

Do you smoke?

Yes, outside only

Yes, only on breaks

Yes but won’t while working

Vape

(Choose one)

What form of transportation will you use to get to work?

Bus

Car

Walk

(Choose one)

Are you willing to use your car to run errands, etc?

Yes

(Choose one)

Would you like to be referred to private pay consumers?

Yes

(Choose one)

Are you fluent in any languages other than English? If yes, please list them here:

Will you work for a smoker?

Yes

Yes, outside only

Yes, no preference

(Choose one)

Are you looking for a live-in position?

Yes

(Choose one)

What is your gender identity?

Do you have a gender preference of the person you work for?

Male

Female

No preference

(Choose one)

Are you willing to drive a consumer’s car to run errands, etc.?

Yes

(Choose one)

Will you work for a consumer with pets?

(Choose one)

Are you willing to work for evacuees during a local emergency or disaster?

Yes

(Choose one)

I am willing to work in the following locations:

Chester

Indian Valley

Portola

Quincy

(Choose all that apply)

I am willing to work in the following locations for EMERGENCIES/BACK-UP PROVIDER:

Chester

Indian Valley

Portola

Quincy

(Choose all that apply)

I am willing to do the following work:

(Choose all that apply)

Education, Training & Experience

Will you provide your work resume?

If yes, please upload resume here:

Max. file size: 256 MB.

If no, please list any applicable education or training you have completed (along with dates):

If no resume is submitted, please list any applicable work experience you have:

(COMPANY NAME, START DATE, END DATE, DUTIES PERFORMED)

Please list any current licenses or certificates you hold (only licenses or certificates attached to this application will be considered).

Attach copies of any relevant licenses or certificates you hold.

Max. file size: 256 MB.

Please explain why you are interested in in-home care.

References

Reference 1 Name

First Last

Reference 1 Phone

Relationship to Applicant

Company name

Reference 2 Name

First Last

Reference 2 Phone

Relationship to Applicant

Company name

Personal Reference Name

First Last

Personal Reference Phone

Relationship to Applicant

Length of time known

Background Check

Note: Please answer the following questions 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 all of the counties you have lived in within the last 10 years.

(COUNTY, STATE, DATES OF RESIDENCE)

Have you ever been convicted of a felony or a misdemeanor charge?

Are you currently or have you ever been on probation?

If you have been convicted of any crimes in the past 10 years, please list them here:

(DATE OF OFFENSE, OFFENSE, SENTENCE, RELEASE DATE)

How did you hear about Connecting Point?

Print name:

Today's date