At Home Care Providers' Network (AHCPN)
108 N. Main Street * Rte.47 * P.O. Box 448 * Sunderland, MA * 01375
Tel:(413) 665-WORK(9675) * www.sunderlandcenter.org

SERVICE REQUEST & AGREEMENT

NAME ____________________________________

HOME PHONE ______________________________WORK/CELLPHONE______________________________

ADDRESS ________________________________________________________________________________

E-MAIL__________

Type Of Service Requested: (Please Check)

___CHILD CARE     ____ ADULT/ELDER CARE    _____OTHER

(If Child Care ): Number, Ages and Genders: __________________________________________

PREFERRED DAYS & TIMES: ________________________________________________________________

GENERAL DUTIES: ________________________________________________________________________

PREFERRED START DATE: END DATE (If Temporary): ____________________________________________

PREFERRED HOURLY RATE (OR WEEKLY SALARY): $_____________

ANY SPECIAL NEEDS or MEDICAL NEEDS?:______________________________________

******************************************************
PLAN A:

THE AT HOME CARE PROVIDERS' NETWORK WILL:
------ OFFER YOU ONE OR MORE POTENTIAL CANDIDATES ON THEIR ROSTER.
THESE CANDIDATES HAVE ALREADY :
------ 1. BEEN INTERVIEWED IN PERSON (If candidate is within 15m of the The Sunderland Office),
------ 2. PRESENTED TWO WORK REFERENCES
------ 3. COMPLETED BACKGROUND CHECKS (CORIS)
COST FOR PLAN A: $100.
THIS INCLUDES A:
------ $50 NON-REFUNDABLE APPLICATION FEE, &
------ $50 FULLY REFUNDABLE FINDER’S FEE FOR A COMPLETED POSITION MATCH.

PLAN B:

THE AT HOME CARE PROVIDERS' NETWORK WILL:
------ ADVERTISE IN THE NEWSPAPER OF YOUR CHOICE FOR A TAILORED JOB-MATCH TO MEET YOUR NEEDS. YOU WILL BE PRESENTED WITH UP TO FOUR RESPONDING INDIVIDUALS, WHO HAVE :
------ 1. BEEN SCREENED BY PHONE,
------ 2. BEEN INTERVIEWED IN PERSON (if candidate is within 15 miles of Sunderland Office),
------ 3. PRESENTED A COVER LETTER AND/OR RESUME + TWO WORK REFERENCES, &
------ 4. COMPLETED BACKGROUND CHECK INFORMATION(CORIS)
COST FOR PLAN B: $325 AND UP.
THIS INCLUDES A:
------ $50 NON-REFUNDABLE APPLICATION FEE,
------ $50 FULLY REFUNDABLE FINDER’S FEE FOR A COMPLETED POSITION MATCH,
------ $125 ALLOWANCE TOWARD ADVERTISING COSTS (non-refundable),
------ $100 CONSULTING TIME ALLOWANCE (TIME REQUIRED TO COMPLETE DAILY PHONE SCREENINGS & UP TO FOUR FACE-TO-FACE INTERVIEWS WITH POTENTIAL `MATCHES’).

AT HOME CARE PROVIDERS' NETWORK WILL NOT:
------ DECIDE WHOM YOU SHOULD HIRE; THIS IS YOUR DECISION.

AT HOME CARE PROVIDER’S NETWORK FURTHER SUGGESTS:
**** AS AT HOME CARE PROVIDERS' NETWORK IS NOT AN EMPLOYER, WE RECOMMEND ALL PERSONS HIRED BY YOU IN ANY CAPACITY WHERE THEY ARE RESPONSIBLE FOR THE CARE OF OTHERS:
------ Complete First Aid & CPR classes and keep up to date,& (If caring for children): Complete any/all additional classes/trainings set by the Office of Child Care Services (413)788-8401.
If EVER driving someone:
------ 1. Have a valid Driver’s License, &
------ 2.Carry the highest insurance recommended by your insurance agent.
------ 3. Present you with original documents to view and copy for your records.

**** AND, THAT YOU ARE IN THE ROLE OF EMPLOYER, IT IS FURTHER SUGGESTED YOU DISCUSS WITH YOUR INSURANCE AGENT AND ACCOUNTANT HOW TO BEST MEET REGULATIONS IN REGARD TO ALL TYPES OF COVERAGE, AND EMPLOYER/EMPLOYEE STATE & FEDERAL OBLIGATIONS. THE PERSON YOU HIRE THROUGH OUR AHCPN PROGRAM IS AN INDEPENDENT CONTRACTOR, AND IN MOST CASES CARRIES NO LIABILITY, WORKER’S COMPENSATION, OR PERSONAL INJURY INSURANCE FOR THEIR WORK.

I have read the above information, and understand the provisions, limitations, and recommendations of the At Home Care Providers' Network, in assisting me in my search for the best qualified individual(s) to provide services to me and/or my family/program.

______ I HAVE CHOSEN PLAN A (My check for $100 is enclosed.)

______ I HAVE CHOSEN PLAN B (My check for $325 is enclosed.)

______ I HAVE CHOSEN TO BEGIN WITH PLAN A, AND AM PREPARED TO MOVE TO PLAN B IF NO ONE ON THE AHCPN’S PRESENT ROSTER MEETS MY NEEDS. I UNDERSTAND THAT I WILL SET MY BUDGET IN ADVANCE OF THIS CHANGE, BUT IN ORDER TO MOVE TO PLAN B, I WILL FIRST COMMUNICATE THIS CHOICE TO THE PROGRAM ADMINISTRATOR, AND PAY, IN ADVANCE, THE ADDITIONAL ESTIMATED AMOUNT OF $225 FOR PROJECTED SERVICES, AS DESCRIBED ON PAGE ONE (my check for $100 is enclosed, and I am prepared to send an additional $225 if I choose to move to PLAN B).

I agree to the above information, and am ready to begin my search.
My check is made payable to "Sunderland Center for Positive Change"

SIGNATURE _____________________________________________

DATE _________________

Revised 7/07

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