Special Thanks to Genevieve & Glen Ghilotti

Special Thanks to Team Ghilotti
Special Thanks to Hunter Spencer
Special Thanks to Wm. H. Donner Foundation
Special Thanks to John & Carri Hammett
Special Thanks to Annual Event volunteers!
Special Thanks to Tom & Carol Wise
Special Thanks to Care.com
"We cannot hold a torch to light another's path without brightening our own! "

Care Provider Application

Introduction of Prospective Care Provider Candidates

Referred by:
I'm applying as: Dad/Mom's helper   Babysitter   Nanny   Nurse
If nurse: LVN   RN  
  Nurse Other (specify)
I am 18 or over: Yes   No
 

Personal Information:
Name:
  Male   Female
Address:
City:
Please select an state.
Zip Code:
Phone Number: Cell
  Land
  Work
Email Address:
 

Care Provider Information:
Days Available:
(weekdays / weekends or specific days)
Times Available:
(weekday eves / all day weekends, nights)
Compensation: $ Range *p/hour
$ Overnight fee
(*Please consider "willing to start at", followed by raises, etc.)
  Check (X) the challenges you are comfortable with and/or willing to train for:
Physical disabilities   Developmental   Behavioral   Medical
  Please list any diagnoses you have worked with:
(cerebral palsy, autism, cystic fibrosis, etc)
  Check (X) if experienced with:
Feeding Tubes   Respirators   Other:
  What is most interesting or enjoyable for you about the prospect of this work:
  Training / Experience / Skills
CPR   Red Cross   TLC Sponsored Training
  Languages (verbal or sign):
1.   2.   3.
  Related Education / Courses:
  Please list relatives/friends/co-workers who have disabilities and their challenges/diagnosis: