Dayle McIntosh Center - Care Provider Registry Application

Date: *

Name: *

Phone 1: *

Phone 2:

Address: *

Email: *

Gender: *

Date of Birth: *

Driver's License Expiration Date:

Do you have reliable mobility? *

Yes

Initial Screening Questions

Have you worked as a caregiver before? *

Yes

how many years of experience? *

Are you currently enrolled as an IHSS care provider? *

Yes

Please provide your IHSS provider number? *

Are you open to becoming an IHSS care provider? *

Yes

Are you willing to complete a live scan background check? *

Yes

Have you had a Covid-19 vaccine? *

Yes

Are you willing to get the vaccine? *

Yes

Preferences

Are you a smoker? *

Yes

Willing to work in a smoking environment? *

Yes

Willing to work around pets?

Yes

If yes, what type of pet:

Cats

Dogs Dogs

Will work with: *

Male

Female

Both

Availability: *

Back-Up

Full-Time

Live-In

Part-Time

Available Days / Times: Morning (until 12 noon); Afternoon (until 5PM); Evening (after 5PM)

	Sun.	Mon.	Tues.	Wed.	Thu.	Fri.	Sat.
Morning	Sun.	Mon.	Tues.	Wed.	Thu.	Fri.	Sat.
Afternoon	Sun.	Mon.	Tues.	Wed.	Thu.	Fri.	Sat.
Evening	Sun.	Mon.	Tues.	Wed.	Thu.	Fri.	Sat.

Cities:

Certification:

Personal Home Care Worker: *

Yes

Date:

First Aid/ CPR (Recommended): *

Yes

Date:

Certified Nursing Assistant (CNA): *

Yes

Date:

Certified Home Health Agency (CHHA): *

Yes

Date:

Licensed Practical or Vocational Nurse (LVN/PN): *

Yes

Date:

Please provide a non-family member reference.

Name: *

Phone: *

Relationship: *

Years Known: *

Comments:

American Sign Language (ASL)	Chinese	English	French
German	Italian	Korean	Spanish
Vietnamese	Other Other

Bathing/Basic hygiene	Bladder/Bowel Assistance	Companionship
Health/Medication Management	Housekeeping	Meals/Cooking
Shopping/Errands	Toileting	Transfer - Minimum
Transfer - Moderate	Transfer - Maximum	Transportation

Commode	Gait Belt	Hoyer Lift	Shower Chair/Bench
Sure Hands	Transfer Board	Walker/Rollator	Wheelchair

Anaheim	Brea	Buena Park	Cypress	Fountain Valley	Fullerton
Garden Grove	Huntington Beach	La Palma	Los Alamitos	Orange	Placentia
Santa Ana	Seal Beach	Stanton	Tustin	Westminster	Yorba Linda

Aliso Viejo	Costa Mesa	Dana Point	Irvine	Laguna Beach	Laguna Niguel
Lake Forest	Mission Viejo	San Juan Capistrano	San Clemente	Rancho Santa Margarita