Home Care Provider Application

Applying Provider Information

Name(Required)

First Middle Last

Address(Required)

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

Phone

Country Phone Number

Mobile Phone

Country Phone Number

Email(Required)

How did you hear about The Moore Center?

Are you legally eligible for employment in the United States? (Proof of eligibility will be required upon employment)(Required)

Are you 18 years of age or older?(Required)

Have you previously worked for The Moore Center?(Required)

If yes, when did you work here?

Have you ever been convicted of a crime which has not been annulled, expunged or sealed by a court (include felonies and misdemeanors)?(Required)

If yes, please explain:

Have you, or anyone else who lives in your home, ever had a client rights violation founded against you?(Required)

If yes, please explain

Applying Provider Education

High School

High School Name(Required)

High School City & State(Required)

Dates Attended - From/To(Required)

Did you graduate?(Required)

Diploma

College

College Name

College City & State

Dates Attended - From/To

Did you graduate?

Degree

Additional Education

Name of Institution

City & State

Did you graduate?

Dates Attended - From/To

Diploma/Degree/Certificate

Home Layout and Match Preferences

Is your home accessible to an individual who uses a wheelchair? Meaning: 1. Do you have a ramp to enter?

Is your home accessible to an individual who uses a wheelchair? Meaning: 2. Are the doorways wide enough to have a wheelchair pass through?

Is your home accessible to an individual who uses a wheelchair? Meaning: 3. Is the restroom large enough to accommodate a wheelchair?

If no, would you be willing to make structural changes to your home to accommodate a wheelchair user?

How many steps are there to get into your home?

Do you have an accessible bathroom on the first floor of your home?

Is there an available bedroom located on the first floor?

Do you have children living in your home?

If yes, what are their ages?

Do you have any pets in your home?

If yes, what kind?

Would you be willing to accept an individual's pet into your home?

If yes, what kind of pets would you accept?

Are you willing to provide personal care service to an individual, for example assistance with using the restroom, changing soiled clothes, showering, feeding, medication administration, dressing etc.

Are you willing to accept an individual who needs behavioral supports around physical aggression that may include the need for physical restraint?

Are you willing to provide care to an individual in your home who needs behavioral supports around verbal aggression including yelling, screaming, swearing and threatening?

Are you willing to have someone living in your home that smokes cigarettes?

Does anyone smoke inside the home?

Do you have an "in-law" apartment or an area that is distinctly separated from the main home that would accommodate an individual with a high level of independance?

Employment History

Beginning with your most recent employer, please list below all present and past employment.

Employer 1

Employer 1 - Name

Employer 1 - Phone number

Employer 1 - City & State

Employer 1 - Supervisor's name & title

Employer 1 - Your last job title

Employer 1 - Final rate of pay

Employer 1 - Brief description of your duties:

Employer 1 - Dates employed (mm/yy to mm/yy)

Employer 1 - Reason for leaving?

Employer 1 - Can we contact this employer?

Employer 2

Employer 2 - Name

Employer 2 - Phone number

Employer 2 - City & State

Employer 2 - Supervisor's name & title

Employer 2 - Your last job title

Employer 2 - Final rate of pay

Employer 2 - Brief description of your duties:

Employer 2 - Dates employed (mm/yy to mm/yy)

Employer 2 - Reason for leaving?

Employer 2 - Can we contact this employer?

Employer 3

Employer 3 - Name

Employer 3 - Phone number

Employer 3 - City & State

Employer 3 - Supervisor's name & title

Employer 3 - Your last job title

Employer 3 - Final rate of pay

Employer 3 - Brief description of your duties:

Employer 3 - Dates employed (mm/yy to mm/yy)

Employer 3 - Reason for leaving?

Employer 3 - Can we contact this employer?

Household Member Information

Please list all adults (related and unrelated not receiving services) in your home over the age of 18 and your relationship to them

Name 1:

Full name

Name 1:

Relationship

Name 1:

Date of Birth

Name 2:

Full name

Name 2:

Relationship

Name 2:

Date of Birth

Name 3:

Full name

Name 3:

Relationship

Name 3:

Date of Birth

Name 4:

Full name

Name 4:

Relationship

Name 4:

Date of Birth

Name 5:

Full name

Name 5:

Relationship

Name 5:

Date of Birth

Do you have any other clients living in your home that are supported by a different vendor?

If yes, which vendor?

References

Personal references only.

Name 1(Required)

Full Name

Name 1(Required)

Relationship

Name 1(Required)

Phone number

Name 2(Required)

Full Name

Name 2(Required)

Relationship

Name 2(Required)

Phone number

Name 3

Full Name

Name 3

Relationship

Name 3

Phone number

Name 4

Full Name

Name 4

Relationship

Name 4

Phone number

Name 5

Full Name

Name 5

Relationship

Name 5

Phone number

Summary

Please provide a brief paragraph about why you want to become a homecare provider

Demonstrates comfort and proficiency in using computers, electronic devices, and software applications to efficiently perform job responsibilities.

Add your comments(Required)

Attachment 1

Max. file size: 192 MB.

Attachment 2

Max. file size: 192 MB.

Application Date

Signature(Required)

Please type your full name

Home Care Provider Application

If you’re interested in becoming a Home Care Provider for The Moore Center, please complete this application.

Applying Provider Information

Applying Provider Education

High School

College

Additional Education

Home Layout and Match Preferences

Employment History

Employer 1

Employer 2

Employer 3

Previous Experience Supporting People with Disabilities

Household Member Information

References

Summary