CHILD & ADULT CARE APPLICATION & AGREEMENT
*** Please print the page and post mail the completed form to the address below. Thank you.***

The Sunderland Center’s
At Home
Care Providers' Network (CPN)
108 N. Main Street * P.O. Box 448 * Sunderland, MA * 01375
Tel:(413) 665-WORK(9675)

CHILD & ADULT CARE APPLICATION & AGREEMENT

NAME:________________________________________
HOME PHONE:_________________________________
WORK PHONE:________________________________
ADDRESS:_____________________________________
DATE:_________________________________________
EMAIL:_________________________________________

Services You Provide: (circle any which apply)

  • CHILD CARE
  • ADULT CARE
  • OTHER( )

PREFERRED DAYS & TIMES:_________________________________________
PREFERRED SALARY:____________ LIVE-IN or LIVE OUT?:_______________
ADDITIONAL PREFERENCES/EXPECTATIONS:_________________________
(If no resume presented, or using e-mail format):

Most Recent Experience: Job Title: Family/Program Name:____________________
Recent Phone number(s): (Day): (Evening):________________________________
Responsibilities: (if childcare, include age(s) of child(ren):______________________
_________________________________________________________________
Dates of employment:________________________________________________
Reason for Leaving:___________________________________________________

****************************************

Job Title: Family/Program Name:____________________
Recent Phone number(s): (Day): (Evening):________________________________
Responsibilities: (if childcare, include age(s) of child(ren):______________________
_________________________________________________________________
Dates of employment:________________________________________________
Reason for Leaving:__________________________________________________

Education/Training/Certification(s):_______________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________


Narrative: (Please share a little about yourself, your experiences, and what you have to offer a family or program):
_________________________________________________________________
_________________________________________________________________

GENERAL AGREEMENT

I hereby attest all the information I have provided is true, provided in good faith, and to the best of my knowledge. By completing this form, requesting links to the consumers I seek, I fully understand that the AT HOME CARE PROVIDERS NETWORK is NOT responsible for the individuals or programs I choose to provide these services to. I also understand this application does not take the place of any contract I might otherwise use when offering my services. The At Home CPN does not carry any insurance for my work. AS THE AT HOME CPN IS NOT MY EMPLOYER, I ALWAYS HAVE THE CHOICE AS TO WHOM I OFFER MY SERVICES TO.

Please read the additional information (both sides of this form), sign, and return.

TO MEET THE NEEDS OF CONSUMERS I WILL COMPLETE THESE PRE-MATCH REQUIREMENTS. I WILL:

  1. BE SCREENED BY PHONE,

  2. PRESENT A COVER LETTER AND/OR RESUME/GENERAL APPLICATION + TWO WORK REFERENCES, &

  3. REQUEST &COMPLETE, BACKGROUND CHECK INFORMATION (CORIS) WHICH WILL BE FORWARDED TO THE OFFICE FOR CHILD CARE SERVICES’(OFCCS) CORI UNIT.

THE AT HOME CPN SUGGESTS :

AS THE AT HOME NETWORK IS NOT AN EMPLOYER, WE RECOMMEND ALL PERSONS RESPONSIBLE FOR THE CARE OF OTHERS:
Complete First Aid & CPR classes and keep up to date, &
  1. (If caring for children): Complete any/all additional classes/trainings set by the
    Office of Child Care Services (413)788-8401.

  2. If EVER driving someone:

  3. Have a valid Driver’s License, &
    Carry the highest insurance recommended by your insurance agent.

  4. Present your employer with original documentation to view & a copy for their records.

AND, THAT YOU ARE IN THE ROLE OF INDEPENDENT CONTRACTOR/ EMPLOYEE, 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 EMPLOYEE STATE & FEDERAL OBLIGATIONS.

FEE SCHEDULE

1.JOB MATCH FEE: $25 due at the start of your first CPN match, and $15 for each match, thereafter. (Fee waived if match is an ADVERTISED position).
I,(Printed Name)_____________________________________ , agree to, and will abide by the expectations described on this service contract.


Signature:_______________________________________________
Date:___________________________________________________

Please complete the form, and send, along with any additional material to the address to (please keep a copy for your records):

The Sunderland Center
At Home Care
Box 448
Sunderland, MA 01375


We will review your application, and contact you if your experience/training matches any of the family or program requests. You may receive additional material to complete and return. Feel free to contact us using e-mail or by calling our message center. If your experience does not match any family/program, you may not hear back from us, however we will keep your information on file for future opportunities/matches.

* Please pay your fees on time (within two weeks of your successful job-match). A LATE FEE OF $10/MONTH will apply to any provider who is consistently late with their fees. Checks are to be made out to SCPC (The Sunderland Center for Positive Change) and are to be sent to:
The Sunderland Center
At Home Care
Box 448
Sunderland, MA 01375

Thank You for your interest in our Care Providers Network.

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