Helping Hands at Home Application
Contact:
Aging and Disability Resource Center of Sauk County
Marina Wittmann, Helping Hand Coordinator
505 Broadway
Baraboo, WI 53913
(608)355-3289 | fax: (608)355-4375
marina.wittmann@saukcountywi.gov
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Email *
Name: *
Street Address: *
City/State/Zip: *
Mailing Address (if different from residential):
Home and/or Cell Phone: *
If you want your email listed in addition to your phone number, list it here:
Do you or someone in your household smoke cigarettes? (The answer to this question will be on the list to protect individuals on oxygen or who have other respiratory conditions): *
How did you learn about the Aging & Disability Resource Center (ADRC)?
Highest Educational Level Completed: *
Certifications, Licenses, CPR, special skills, languages: *
Services you are able to provide. (This is your small listing for the Helping Hands at Home list so please be specific): *
Please check the locations you are able to provide services: *
Required
Work History - Please list your current and/or last employer, dates employed, and describe the work that you did: *
Reference - Please list a non-family member we may call who would be willing to provide a character reference for you (Name, Phone Number, Address, Relationship to You): *
It’s our policy to conduct criminal background checks on all potential workers. The information will beheld in strict confidence, will not be shared with any other entity or used for other purposes. Once your criminal background check is completed, assuming your criminal background check is clear of any crime which could endanger the population served by the ADRC, you will be asked to interview with ADRC staff. You must renew your application and background check annually.
Signing below certifies that all the information above is correct and that you will abide by the policy stated above.
Applicant Signature: *
Date: *
The information you are being asked to provide is needed to determine if you are eligible to be placed in our Helping Hands at Home list. This information will be stored in a secure electronic database and will not be used for any other purpose. Your information will not be shared with another agency without your permission. This information will not be sold to anyone. The ADRC reviews your information, including conducting a criminal background check. Assuming your information and criminal background check is clear of any crime which could endanger the population served by the ADRC, your name will be added to the Helping Hands at Home brochures distributed by the ADRC. If you have any questions regarding this, please ask the ADRC staff.
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