IN-HOME REGISTRY APPLICATION

Provided by

GOLDEN UMBRELLA

200 Mercy Oaks Drive, Redding, 96003 - (530) 223-6034 - FAX (530) 223-0658

( ) DMV Print Out ( ) Registry Fee Paid

( ) Photocopy of California Drivers License or ID Card Date:________________

( ) Fingerprints (Live Scan form attached)

( ) References Checked: 1__ 2__ 3__

Name:_____________________________________________Phone:_____________

Address: _____________________________________________________________

City: __________________________ State: ______ Zip Code: __________________

Date of Birth: __________________ California DL# or ID#:______________________

List your last three local employers:

1. Business Name: _______________________________Phone:________________

Address:______________________________________________________________

Supervisor: __________________ Date started: ___________ Date ended: _______

Reason for leaving:____________________________________________________

2. Business Name: ______________________________ Phone:________________

Address: _____________________________________________________________

Supervisor: __________________ Date started: __________ Date ended: _________

Reason for leaving: _____________________________________________________

3. Business Name: ________________________________ Phone: ______________

Address: _____________________________________________________________

Supervisor: _________________ Date started: ___________ Date ended:__________

Reason for leaving: _____________________________________________________

List three: LOCAL non-related and non-employer references:

1. Name:_________________________________________ Daytime phone:__________________

Address:__________________________________________ Length of acquaintance: ______ years

2. Name:_______________________________________ Daytime Phone:____________________

Address:__________________________________________ Length of acquaintance: ______ years

3. Name:________________________________________ Daytime Phone:___________________

Address:__________________________________________ Length of acquaintance: ______ years

Have you ever been on the Registry?________________ If so, when?_____________

Are you signed up to work with the Shasta County In-Home Supportive Services Program?

(For clients that are eligible for IHSS ONLY, the caregiver must be signed up with the program.

YES ( ) NO ( )

Will you work for clients who are in the IHSS program? YES ( ) NO ( )

Check ALL areas of service that you are willing to provide as a CAREGIVER:

( ) Housekeeping ( ) Personal Assistance ( ) Yard Work ( ) Painting

( ) Cooking ( ) Companion ( ) Maintenance ( ) interior

( ) Shopping ( ) Respite Care ( ) Handyman ( ) exterior

( ) Driving ( ) Hospice Care ( ) Electrical

( ) Child Care ( ) Live In Arrangements ( ) Plumbing

( ) Pet Sitting ( ) House Sitting ( ) Carpentry

List any “Special qualifications”:____________________________________________

_____________________________________________________________________

List the cities that you are willing to work:____________________________________

PLEASE READ CAREFULLY BEFORE SIGNING THIS FORM

I certify that the information contained in this application is true and correct. I authorize all previous employers and references to give any information needed to Golden Umbrella, in order to evaluate my work experience and personal character.

I am aware that as a condition of my name being placed on the Golden Umbrella Registry, I will be required to successfully complete a screening process and to submit all records and/or information requested.

My signature below signifies that I recognize that my placement on the Golden Umbrella Registry is subject to the discretion of Golden Umbrella and that, should I be placed on the Registry, my name can be withdrawn by the Golden Umbrella at their sole discretion.

I further understand that I am NOT an employee of the Golden Umbrella, but self-employed, and work for private pay. If I am signed up with Shasta County’s In-Home Supportive Services, then I will be paid through Shasta County.

I, the undersigned hereby release and agree to indemnify and hold harmless Golden Umbrella, Mercy Medical Center, Catholic Healthcare West and Catholic Healthcare West II, from and against any and all injuries to or deaths of persons and claims, demands, cost, loss, damage and liability, howsoever same may be caused whether directly or indirectly made or suffered by the undersigned, the undersigned’s agent, subcontractor and/or employee of such subcontractor while engaged in the Registry Program.

Signature:_____________________________________ Date:___________________

Revised 7/27/2011