Direct Support Professional Application
Please enter the your name below as it appears on your Social Security, Identification or Drivers License.
Please tell us a little of your work history and why you want to work with individuals with special needs
*
0/1500
Are you currently pending or have you ever been convicted of a Felony or Misdemeanor?
*
Yes
No
How soon can you begin working?
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Month
-
Day
Year
Date
First Name
*
Middle Name
Last Name
*
Date of Birth
*
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Month
-
Day
Year
Date
Preferred Method of Contact
*
Please Select
Call
Text
Email
Cell Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
*
Is your mailing address the same as your street address?
*
Yes
No
Mailing Address (if different than above)
City
State
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
Preferred Language
*
Please Select
English
Spanish
Afrikaans
Ahtena
Albanian
Aleut
AmericanIndian
Amharic
Apache
Arabic
Armenian
Assamese
Athapascan
Aztecan
Bantu
Basque
Bengali
Berber
Bielorussian
Bihari
Bikol
Bisayan
Bulgarian
Burmese
Cantonese
Carolinian
Caucasian
Chadic
Chamorro
Cherokee
Cheyenne
Chibchan
Chinese
Choctaw
Cocomaricopa
Cree
Croatian
Cushite
Czech
Dakota
Danish
DeltaRiverYumanan
Dravidian
Dutch
Efik
Eskimo
Estonian
Fijian
Finnish
Formosan
French
FrenchCreole
Fulani
German
Greek
Gujarati
Hakka
Havasupai
Hawaiian
Hebrew
Hidatsa
Hindi
Hmong
Hopi
Hungarian
Hupa
Icelandic
Ilocano
Indianec3
Indonesian
Inupik
IrishGaelic
Italian
JamaicanCreole
Japanese
Kannada
Karen
Kazakh
Keres
Kiowa
Kirghiz
Korean
Krio
Kru,Ibo,Yorubaa
Kurdish
Laotian
Latvian
Lithuanian
Luxembourgian
Macedonian
Malay
Malayalam
Mandan
Mandarin
Mande
Marathi
Marshallese
Mayanlanguages
Mbum(andrelated)ed)
Melanesian
Mien
Mohave
Mohawk
Mongolian
Mon-Khmer,Cambodianodian
Munda
Navajo
Nepali
Nilo-Saharan
Nilotic
Norwegian
Ojibwa
Omaha
Oriya
Ossete
Otherandunspecifiecifie
Oto-Manguen
Ottawa
Paiute
Pakistannec3
Palau
Pampangan
Panjabi
Pashto
Patois
PennsylvaniaDutchtch
Persian
Pima
Polish
Polynesian
Pomo
Portuguese
Quechua
Rajasthani
Romanian
Romany
Russian
Sahaptian
Samoan
SanCarlos
Scandinavianlanguagnguag
ScotticGaelic
Sebuano
Serbian
Serbocroatian
Shoshoni
Sindhi
Sinhalese
Siuslaw
Slovak
Slovene
SouthernPaiute
Sudanic
Sundanese
Swahili
Swedish
Syriac
Tagalog
Tamil
Telugu
Tewa
Thai
Tibetan
Tongan
Towa
Trukese
Tungus
Turkish
Uighur
Ukrainian
Uncodable
Urdu
Vietnamese
Walapai
Wu
Yapese
Yaqui
Yavapai
Yiddish
Yuma
Yupik
Zuni
Do you speak English
*
Yes
No
Do you speak Spanish?
*
Yes
No
Gender
*
Please Select
Male
Female
N/A
Race
*
Please Select
Black
Caucasian
Asian
American Indian
Hispanic
Pacific Islander
Alaskan Native
Marital Status
*
Please Select
Single
Married
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Identification
We need the following to run your background check.
Drivers License or ID Number
*
Drivers License or ID State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Drivers License or ID Expiration Date
-
Month
-
Day
Year
Date
Upload a photo of your Drivers License or ID Card
*
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Social Security Number
*
Upload a photo of your Social Security Card (Front & Back)
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Optional
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Availability
What is your work availability? (Through the week and/or weekends)
*
0/500
What is the Maximum distance you would be willing to travel from your home to work with a client (in Miles).
*
Do you own a car?
*
Yes
No
Please list any allergies(Dogs, Cats, etc..) and or medical conditions that might effect your work.
0/2000
Certifications/Documentation
If you don't have the certifications or documentation listed below just go ahead and skip the questions. Don't worry! We will help you obtain all the necessary training.
Upload First Aid/CPR Certification
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First Aid Expiration Date
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Month
-
Day
Year
Date
CPR Expiration Date
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Month
-
Day
Year
Date
Upload Article 9 Certification
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Article 9 Expiration Date
-
Month
-
Day
Year
Date
Upload DCW Certification
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Fingerprint Clearance Card Number
Fingerprint Clearance Card Expiration
-
Month
-
Day
Year
Date
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Finding the right match
The clients we serve have a wide range of needs, some clients only need basic supervision, while others may need total care. Please answer yes or no to the following questions, so we can make sure we pair you with a client that you would be comfortable supporting.
Would you be comfortable working with a client that could be verbally abusive? (Name calling, yelling, etc..)
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Yes
No
Would you be comfortable working with a client that could be physically abusive? (Kicking, biting, hitting, etc...)
*
Yes
No
Would you be comfortable working with a client that is considered a flight risk? (Where you may have to run after them if they wander off)
*
Yes
No
Would you be comfortable working with a client that needs help moving around? (Wheelchair, uses walker or cane)
*
Yes
No
Would you be comfortable working with a client that needs help tolieting?
*
Yes
No
Would you be comfortable working with a client that need help dressing?
*
Yes
No
Would you be comfortable working with a client that needs help bathing?
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Yes
No
Would you be comfortable working with a client that needs help with her mensuration?
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Yes
No
Would you be comfortable working with a client that acts out sexually? (Public masturbation, Groping)
*
Yes
No
Would you be comfortable working with a client that needs you to transport them in your own vehicle?
*
Yes
No
Do you have any note or limitation to the above questions? Please note them here
0/1000
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To hire you we will need 3 references.
Professional references are preferred
Reference 1
Full Name
*
Relationship
*
Please Select
Professional
Acquaintance
Friend
Phone Number
*
Please enter a valid phone number.
Years Known
*
Reference 2
Full Name
*
Relationship
*
Please Select
Professional
Acquaintance
Friend
Phone Number
*
Please enter a valid phone number.
Years Known
*
Reference 3
Full Name
*
Relationship
*
Please Select
Professional
Acquaintance
Friend
Phone Number
*
Please enter a valid phone number.
Years Known
*
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Resume
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If you have a resume, please attach it here.
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I attest this application is a true and accurate statement of facts.
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DL FileName
SS FileName
FACPR FileName
A9 FileName
DCW FileName
Resume FileName
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