Application - HOME SWEET HOME CAREGIVERS CORP

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Section 1: Personal Information

First Name *

Middle Initial

Last Name *

Address *

City *

State *

Zip *

Home Phone

Cell Phone *

Fax

Email Address *

Date of Birth

MM slash DD slash YYYY

Social Security Number

Section 2: Desired Position

Position *

Date Available to Start *

MM slash DD slash YYYY

Are you currently working?

Yes

If so, may we contact the company and/or nurse registry?

Yes

Section 3: Education

(Applicants must have a High School Diploma or a GED. Those without either of these requirements cannot be considered.)

Do you have your GED (General Educational Diploma)? *

Yes

Do you have your High School Diploma? *

Yes

High School

Address

Date Graduated *

MM slash DD slash YYYY

Diploma

College/University

Address

Date Graduated

MM slash DD slash YYYY

Degree

Training Program *

Address

Date Graduated *

MM slash DD slash YYYY

Certification/s *

Section 4: Work History

Company Name 1 *

Position *

Address

Phone

Date From

MM slash DD slash YYYY

Date To

MM slash DD slash YYYY

Manager's Name

Company Name 2

Position

Address

Phone

Date From

MM slash DD slash YYYY

Date To

MM slash DD slash YYYY

Manager's Name

Section 5: Professional License and/or Certification

List

Type *

License/Certification #

Date Issued

MM slash DD slash YYYY

Expiration

MM slash DD slash YYYY

State Issued

Upload Certifications/Professional Licenses *

Max. file size: 512 MB.

Upload Driver’s License *

Max. file size: 512 MB.

Upload Resume *

Max. file size: 512 MB.

Section 6: Additional Information

Have you had a break in providing services under your license or certification for greater than 180 days?

Yes

Are you eligible to work in the United States? *

Yes

If no, brief explanation

Have you maintained continuous U.S. residency for at least five years?

Yes

Have you ever been convicted of a crime?

Yes

If yes, please explain conviction(s), when, where and disposition of case(s).

Please note that convictions will not necessarily disqualify your consideration with the nurse registry

Do you have a valid driver's license? *

Yes

Proof of Automobile Insurance?

Yes

Language Spoken

English

Spanish

Portuguese

Creole

Additional languages spoken, please indicate:

Section 7: Availability

Monday

Day

Nights

Overnights

Tuesday

Day

Nights

Overnights

Wednesday

Day

Nights

Overnights

Thursday

Day

Nights

Overnights

Friday

Day

Nights

Overnights

Saturday

Day

Nights

Overnights

Sunday

Day

Nights

Overnights

Hours (Indicate)

Please indicate if you are available to work any shift?

Yes

Are you willing to accept a live-in assignment?

Yes

Statement Regarding Registration: The information contained in this registration packet is complete and accurate. I hereby authorize verification of any and all information contained in this registration packet and on my resume provided. The Nurse Registry Referrral opportunities are contingent upon furnishing evidence of identity, proof of eligibility to work in the United States and qualifications required by AHCA (Agency for Health Care Administration) and Federal/State Law making authority.

I certify that such statements are true and understand that misrepresentation or omission of facts on this form and/or on the resume provided by me, could void this agreement without notice.

Independent Contractor's Signature *

Date *

MM slash DD slash YYYY

Independent Contractor’s Name

THIS NURSE REGISTRY IS AN EQUAL CLIENT REFERRAL OPPORTUNITY AND NO PERSON SHALL BE DENIED REFERRAL OPPORTUNITIES ON THE BASIS OF RACE, AGE, ETHNICITY, NATIONAL ORIGIN, GENDER, SEXUAL ORIENTATION, RELIGION, CREED, VETERAN STATUS, MARITAL STATUS, DISABILITY OR ANY OTHER LEGALLY PROTECTED STATUS.

Emergency Contact Information

In compliance with Florida AHCA regulations, all independent contractors and staff working through a nurse registry must provide up-to-date emergency contact information. This information must include: A minimum of two emergency contacts and at least one contact who is a next-of-kin.

Independent Contractor's Name *

Start Date

MM slash DD slash YYYY

Address *

City *

State *

Zip *

Telephone *

Alternate

Date of Birth *

MM slash DD slash YYYY

Please contact the following next of kin and/or designee listed below:

Next of Kin

Name *

Relationship *

Address *

City *

State *

Zip *

Telephone *

Alternate

Second Emergency Contact

Name *

Relationship *

Address *

City *

State *

Zip *

Telephone *

Alternate

Release Protected Health Information (PHI) And Criminal Background Screening Data

I acknowledge that my protected health information (PHI) and criminal background screening data will be maintained confidentially by the nurse registry. I also understand that this information may not be discussed with anyone, either inside or outside of the nurse registry (except as needed to conduct the business of the day). I also acknowledge that my protected health information and background screening data are not to be disclosed to anyone outside of the nurse registry unless I sign a form authorizing this release of information.

I understand that, by signing this form I am authorizing the nurse registry to release my protected health information and background screening data to another entity that is required by law to confirm and document this information for my contract and interaction with patients. In addition to releasing this information to other home health nurse registries, home health agencies for contract purposes, I also authorize the nurse registry to release my protected health information and criminal background screening information to surveyors conducting an investigation of the nurse registry.

Independent Contractor's Signature *

Date *

MM slash DD slash YYYY

Independent Contractor's Name *

Please share any additional information you feel may support your application.

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Caregiver Application

Section 1: Personal Information

Section 2: Desired Position

Section 3: Education

Section 4: Work History

Section 5: Professional License and/or Certification

List

Section 6: Additional Information

Section 7: Availability

Emergency Contact Information

Please contact the following next of kin and/or designee listed below:

Release Protected Health Information (PHI) And Criminal Background Screening Data

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