Apply to Become a Provider

General Information

Do we have your premission to send you text message?

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:

Pronouns:

Other Pronoun:

Ethnicity:

Other Ethnicity:

Languages

English Fluency Level:

Accessibility

Do you rely on public transportation to get to jobs?

Are you willing to use your own car to transport your Consumer(s)?

Are you willing to drive a Consumer's car?

* 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?

Completion Date:

Have you completed the Homebridge Basic 48-hour Training Online?

Completion Date:

Have you completed Homebridge Workshop(s) or Specialized Training(s)?

Are you certified in First Aid / CPR? (Cardio-Pulmonary Resuscitation)

Certification Date:

Do you have a Tuberculosis Test Clearance?

Test Result Date:

Do you have proof of COVID-19 vaccination?

Last Vaccination Date:

Other Relevant Information

Do you smoke? (Must not smoke indoors.)

Will you work for consumers who smoke?

Do you have an allergy that would affect your ability to work in a home with? (Check all that applies.)

Describe other allergy:

Are you willing to provide IP services in the event of a disaster?

Check all that applies:

Do you wear any type of scent, cologne, or perfume?

Are you willing to work with Consumers with scent in their 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:

Domestic Tasks:

Client Types:

Personal Tasks:

Schedule & Geographic Preferences

What are the number of hours per week you would be willing to work?

Please check whether you want short-term and/or long-term jobs. (You may answer both options.)


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.

Work History

List one verifiable work reference (home care experience preferred),
or volunteer work experience within the past five years:

Permission to Call:

Period of Employment: (Starting date to ending date.)

to

Personal References

List two personal references who are not relatives.
Please do not list family members (sisters, nieces, grandparents, etc.)

Acknowledgement & Consent:

Please check all boxes below acknowledge and consent: