Respite Providers Sign Up Here
Register
Welcome to the Caring Communities Respite Care Registry! Please fill out your information as thoroughly as possible. You will be emailed a confirmation of your username and password for the account.
PLEASE NOTE: AGENCIES THAT PROVIDE RESPITE CARE SERVICES MAY SIGN UP IN THE CARING NETWORK TOO!
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= REQUIRED FIELD
Email (this will be your username)
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:
Password
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:
Repeat Password
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:
First Name
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:
Middle Name:
Last Name
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Address
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City
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State
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Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
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Gender
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Select One
Male
Female
Phone
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Cell:
Fax:
Smoker Status
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Select One
Smoker
Non-Smoker
Allergic to pets
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:
Select One
No
Yes
Do you speak a foreign language (if yes please list):
Do you know sign language?
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Select One
No
Yes
List any restrictions to your service (ie. Medical Conditions, transportation etc):
Do you have childcare experience?
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Select One
No
Yes
Number of Years:
Ages of Children:
Childcare Background:
Do you have adult care experience?
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:
Select One
No
Yes
Number of Years:
Adult Care Background:
Do you have experience with children/adults who have disabilities?
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:
Select One
No
Yes
Have you ever had a Background Check? If so when:
If you would like Caring Communities to arrange a simple background check, we will send you the form. There will be a processing fee of $25. You would receive a copy of the report for your records. Most families will strongly suggest that a Background Check be performed before working in their home (this is not required to be entered into the Caring Network Registry). Please e-mail
info@caringcommunities.org
for more info.
List Certificates, Licenses and relevant training or skills (ie, RN, LPN, CNA):
Check personal experience/training that apply:
CPR
First Aid
Red Cross
Babysitting
Seizure training
Sibling/Family member
Alzheimer Training
Autism training
Other/Specialty Medical Training (specify)
Other Training Experience:
Would you care for an individual
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:
Select One
Over 50 lbs
Over 100 lbs
Over 150 lbs
Over 200 lbs
Over 250 lbs
Any weight is fine with me
How many miles are you willing to drive to provide respite care?
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:
Please check the days you are available to provide respite care:
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Week Days M-F
Week Nights M-F
Weekend days
Weekend Nights
Will you furnish references upon request?:
Select One
No
Yes
Provider Terms
I understand that my provider information will be available to anyone registering to use the Caring Network. I certify that statements made by me on this form are true and correct. I understand that if I made any false statements that I can be prohibited from joining the registry or dismissed from the registry. Any misconduct or anything that should be deemed inappropriate by Caring Communities will be grounds for immediate dismissal from the Caring Network, including a background check that is not clean. Additionally, I give the family permission to investigate all references and to secure additional information about me.
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