Apply to Become a Provider Please correct the following errors: General Information First Name: MI: Last Name: Preferred Name: Mailing Address: City: State: Zip Code: Residential Address: City: State: Zip Code: Email Address: Cell Phone: Home Phone: Other Phone: Do we have your premission to send you text messages? Yes No IHSS Provider #: Optional Information This section is OPTIONAL but may provide useful information to the Registry. Gender will be used only when a consumer requests a worker of the same gender to provide personal care. Gender: Male Female Transgender Male to Female Transgender Female to Male Another Gender Identity Non-Binary Declined to State Identity Pronouns: He/Him She/Her They/Them Ze/Hir Other Other Pronoun: Ethnicity: White Black Latinx Asian / Pacific Islander Other Other Ethnicity: Languages Preferred Spoken Language: (Including English.) Preferred Written Language: (Including English.) Other Language: English Fluency Level: Fluent Limited No English Accessibility Do you rely on public transportation to get to jobs? Yes No Are you willing to use your own car to transport your Consumer(s)? Yes* No Are you willing to drive a Consumer's car? Yes* No * If yes, you must have a current driver's license and auto insurance. IHSS does not pay for transportation services; gas, mileage, maintenance, etc. Training & Certification Have you completed the Homebridge Basic 48-hour Training? Yes No Completion Date: Have you completed the Homebridge Basic 48-hour Training Online? Yes No Completion Date: Have you completed Homebridge Workshop(s) or Specialized Training(s)? Yes No Name of Workshop(s) or Specialized Training(s): Completion Date: Are you certified in First Aid / CPR? (Cardio-Pulmonary Resuscitation) Yes No Certification Date: Do you have a Tuberculosis Test Clearance? Yes No Test Result Date: Do you have proof of COVID-19 vaccination? Yes No Last Vaccination Date: Number of Years of Caregiving Experience: No Experience 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30 Years 31 Years 32 Years 33 Years 34 Years 35 Years 36 Years 37 Years 38 Years 39 Years 40 Years 41 Years 42 Years 43 Years 44 Years 45 Years 46 Years 47 Years 48 Years 49 Years 50 Years 51 Years 52 Years 53 Years 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years Other Relevant Information Do you smoke? (Must not smoke indoors.) Yes No Will you work for consumers who smoke? Yes No Do you have an allergy that would affect your ability to work in a home with? (Check all that applies.) Cats Dogs Other Describe other allergy: Are you willing to provide IP services in the event of a disaster? Yes No Check all that applies: Consumer's Home Emergency Shelter Do you wear any type of scent, cologne, or perfume? Yes No Are you willing to work with Consumers with scent in their home? Yes, I'm willing to work with people who use scents. No, I must work in scent-free home. Work Preferences Please check boxes indicating all your preferences / that which you are willing to work with: We cannot guarantee that consumers service needs will match all your preferences. We encourage you to consider performing all tasks and serving all consumers. Client Gender: Males Females Other / Non-binary Domestic Tasks: Accompaniment to Alternate Resources Accompaniment to Medical Appointments Domestic Services Heavy Cleaning Meals Clean Up Other Shopping & Errands Paramedical Services Preparation of Meals Protective Supervision Yard Hazard Abatement Remove Ice / Snow Routine Laundry Shopping for Food Teaching & Demonstration Client Types: Child / Minor Cognitive / Psych Disability Palliative Care Personal Tasks: Respiration Bowel & Bladder Care Feeding Routine Bed Baths Dressing Menstrual Care Ambulation Moving In / Out of Bed Bathing / Oral Hygiene / Grooming Rubbing Skin / Repositioning Care & Assistance with Prosthesis Set Up / Remind Meds Catheter / Colostomy Bag Diapers Exercise Hoyer Lift Lifting / Transferring Memory Problems Toileting Vital Signs Schedule & Geographic Preferences What are the number of hours per week you would be willing to work? 10 hours per week or less (part-time) 10-25 hours per week (part-time) 25 hours per week or more (full-time) Please check whether you want short-term and/or long-term jobs. (You may answer both options.) Short-Term (Temporary) Long-Term Check all the days and times you are available to work weekly: (Check all that applies.) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Mornings Anytime between 6am – 12pm Afternoons Anytime between 12pm – 5pm Evenings Anytime between 5pm – 10pm Overnights Anytime between 10pm – 6am * Most consumers need part-time workers. You can accept more than one part-time job if you prefer a full-time schedule. Please check off all the locations you would be willing to work: If you are willing to travel to many areas, you may be referred to more jobs. Bayview Bernal Heights Castro Chinatown Civic Center Cole Valley Downtown / Financial District Duboce Triangle Embarcadero / Northern Waterfront Excelsior Fisherman's Wharf Glen Park Haight Ashbury Hayes Valley Ingleside Inner Sunset Japantown Lower Haight Marina Mission Bay Mission District Nob Hill Noe Valley North Beach Outer Sunset Pacific Heights Pacific Heights / Lower Pacific Heights Parkside / Lake Merced Portola Potrero Hill Presidio Richmond Russian Hill SoMa South Beach Tenderloin Treasure Island Twin Peaks Visitacion Valley Western Addition West Portal San Francisco neighborhood you live in: Bay Area county you live in: Work History List one verifiable work reference (home care experience preferred), or volunteer work experience within the past five years: Employer: Phone: Job Title & Responsibilities: Job Supervisor's or Consumer's Name: Permission to Call: Yes No Period of Employment: (Starting date to ending date.) Choose month… January February March April May June July August September October November December Choose year… 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 to Choose month… January February March April May June July August September October November December Choose year… 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 Reason for Leaving: Personal References List two personal references who are not relatives. Please do not list family members (sisters, nieces, grandparents, etc.) Name #1: Phone: Relationship: Name #2: Phone: Relationship: Registry Referral Please tell how did you learn about the Registry Program: Choose one… Flyer IHSS Orientation Job Fair LiveScan Department (Fingerprinting) Presentation Other Please describe other method of referral: Acknowledgement & Consent Please check all boxes below acknowledge and consent: I certify that all information on this form is true to the best of my knowledge and that any omission or misrepresentation of information may disqualify me from being listed in the registry. I also understand that submitting an incomplete application will disqualify me from being considered for the Registry. I understand the Public Authority is a referral agency, and job placement is not guaranteed. I give the Public Authority permission to share relevant information in my file with individual Consumers who are looking for Independent Home Care Providers. I agree to keep confidential all information regarding Consumers and services I provide. I understand that per state law if I knowingly and intentionally violate this confidentiality agreement, I would be guilty of a misdemeanor. I authorize the SF IHSS Public Authority (SFIHSSPA) and its consumers to contact me via text messages to my cell phone and telephone calls as well. I understand that text messaging rates will apply to any messages received from the SFIHSSPA. I also understand that I can opt-out at any time. I agree not to hold SFIHSSPA liable for any electronic messaging charges or fees generated by this service. I further agree that in the event my contact/cell phone number changes that I will inform SFIHSSPA or be liable for any fees or charges incurred. Additionally, SF IHSS Public Authority staff can also contact me through my e-mail address (If provided) and by mail as well. Submit Your Application