SEIU ULTCW Homecare Exchange | Home Care Exchange

First Name*

Middle Name

Last Name*

Address*

City*

State/Region/Province*

Zip/Postal Code*

Home phone*

Cell phone

Date of Birth (mm/dd/yyyy)

Gender*

I am a (check one):*

IHSS-authorized care recipient
private pay care recipient

Complete one of the following three items:

IHSS Social Worker’s name:

IHSS Case #:

Social Security #

List the names and phone numbers of two people we can contact in case of an emergency.

Emergency Contact 1*

Emergency Contact 1 Phone #:*

Emergency Contact 2 Phone #:

Emergency Contact 2

What languages do you speak?

Primary*

Secondary

Other

If you require a provider with additional skills, please specify:

Check the days and times when you might be willing to schedule services

For how many IHSS/Direct Pay hours per month are you hiring?*

If personal care is involved, which gender care provider would you prefer?*

Male
Female
Either

Choose one of the following statements:*

I’d like the Homecare Exchange to give me the names and phone numbers of care provider applicants so that I can contact them myself.
I authorize the Homecare Exchange to give out my name, telephone number, and other information to care provider applicants, so that they may contact me.

Do you require that your provider not use scented fragrances on the job?*

Yes
No

Do you have a dog?*

Yes
No

Do you have a cat?*

Yes
No

Are you a smoker?*

Yes
No

Do you allow others to smoke in your house?*

Yes
No

NOTE: If the care consumer was assisted in completing this application, print the name and telephone number of the person who assisted.

I certify that I have carefully reviewed and considered each and every one of the terms and conditions of this Agreement, understands them, and has decided voluntarily to agree with them. It is understood that the Homecare Exchange and its affiliates will rely upon this Agreement when granting Homecare Exchange participation and services to the undersigned Homecare Exchange participation. Click here to read the Agreement.*

* denotes required field