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SOLANO COUNTY

Public Authority Registry Caregiver Application

Section 1 of 11

Caregiver form will time out in 60 minutes.

Name:

*Required  
*Required  

Address

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Mailing Address (If Different)

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Please Select at least one item*  
Time Slot IDDays and hours availableMondayTuesdayWednesdayThursdayFridaySaturdaySunday
1 Early Mornings: (6am-8am)
2 Mornings: (8am-12pm)
3 Afternoons: (12pm-3pm)
4 Late Afternoons: (3pm-5pm)
5 Evenings: (5pm-9pm)
6 Nights: (9pm-12am)
7 Overnight: (12am-6am)

 

I want to work up to hours per week*

Please check all the cities you are willing to work in*

 






 

I am also willing to work these assignments.





Languages

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Experience and education:

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Please list current certifications, licences and trainings related to Caregiving





Clients I am willing to work with

Conditions/Client Type(check all you are willing to work with)*

 


Transfer Assistance needed

IHSS Tasks I am willing to complete:*

 








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Supplemental Questions

1. What made you choose to be a caregiver? * 
2. What are your strongest assets as an employee and as a caregiver? * 

Gender:

I certify that the information on this application is true. I understand that any false information may eliminate me from consideration.

I understand that the information on this application may be shared with prospective employers and their designees. I understand that my employer is not Solano County In-Home Supportive Services (IHSS) and not Solano County IHSS Public Authority. The IHSS recipient is my employer.

I understand that as part of my application process, I give permission to the Solano County IHSS Public Authority to contact and receive information from my work references about my work history. (Valid for up to one year from date of signature.)

I understand that if I am accepted onto the Public Authority Caregiver Registry, my name may be included on lists given to persons who are seeking assistance in their homes (IHSS recipients and their designees). The IHSS Public Authority retains the exclusive right to list, refer, suspend, or remove an individual caregiver from the registry.

I understand that the Solano County IHSS Public Authority Removal from the Registry Policy outlines minor and major compliant violations, which includes no use of drugs and alcohol in the workplace. Substantiated violations to our policy would be grounds for removal from the Caregiver Registry.

I understand that if I am accepted onto the Public Authority Caregiver Registry, Solano County IHSS Public Authority accepts no liability for Registry Caregivers who choose to use their private vehicles to complete authorized IHSS tasks. It is recommended that Registry Caregivers consult with their private auto insurance carriers.

I understand that I am responsible for paying the fees associated with the Criminal Background Investigation (Livescan for DOJ). I understand that passing Livescan does not guarantee employment.

I understand that the Public Authority does NOT guarantee employment. The Public Authority Provider Registry is a referral service for IHSS recipients and providers; it is not an employment agency.

  Friday, September 25, 2020

All HSS Authority applicants must disclose any criminal convictions(both felonies and misdemeaners, including please of no contest on this application.