Independent Provider Application
This application is to be an Independent Provider on the Care Connection registry, to serve seniors living in Thurston and Mason Counties. If you wish to become a Care Connection client please contact the Care Connection office: care@southsoundseniors.org
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Email *
Personal Information
First Name: *
Last Name: *
Physical Address: *
City, State, Zip: *
Phone: *
Date of Birth: *
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How long have you lived in Washington? *
Work and/or Volunteer History
Beginning with the most recent, please list ALL companies or persons that you have worked/volunteered at within the last ten years, along with dates worked and specific duties.
Name of company *
Start date: *
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End date: *
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Duties *
Name of company
Start date:
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End date:
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Duties
Name of company
Start date:
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End date:
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Duties
Name of company
Start date:
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End date:
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Duties
Experience
Check all that you either have experience with or are willing to learn. Leave all others blank. Experiences listed below should match job duties you listed above.
Have experience
No experience but willing to train and/or gain experience
Alzheimer/Dementia
Hospice/End of Life Care
Parkinson’s
Injection
Wound Care
Catheter Care
Administering / Managing Medication
Meal Preparation
Feeding Assistance
Housework (light)
Housework (medium)
Housework (maximum)
Bowel and Bladder management
Bathing and Hygiene
Personal Care
Shopping/Errands/Transportation
Physical Therapy/Range of Motion
Companionship
Socialization
Gait belt
Hoyer
Sit to stand
Minimum Transfer Assistance (25%)
Moderate Transfer Assistance (50%)
Maximum Transfer Assistance (75%)
Full Transfer Assistance (100%)
Licenses and certifications
These are not required at this time, but let us know the status of each.
Do you have a business license? *
Do you have malpractice insurance? *
If you answered yes to the previous question, enter the expiration date of your malpractice insurance
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Do you have CPR certification? *
If you answered yes to the previous question, enter the expiration date of your CPR certification.
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Do you have a valid driver's license? *
If you answered yes to the previous question, enter the expiration date of your driver's license.
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Have you ever been convicted of a crime? *
If you answered yes to the previous question, please explain.
How did you hear about Care Connection? *
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