REQUEST FOR CERTIFICATION
Select Your Region:
Select
Region I
Region II
Region III
Full Name:
Email Address:
Address(Street):
Street Street Town/City Zip Maine
Phone Number:
Soc. Sec. Number:
Birthdate:
Driver's License #:
OCCUPATION
Employer:
Position:
Employer Address:
Street Street Town/City Zip Maine
Work Phone:
EDUCATION
High School:
College/Univ:
Degree(s):
BACKGROUND AND INTERESTS
Do you have experience caring for children with developmental emotional/behavioral disabilities?
Select
Yes
No
If yes, please submit your credentials (licenses, certificates) to the respite agency.
Are you currently certified in CPR and/or First Aid?
Select
Yes
No
If yes, please list dates:
Can you communicate using American Sign Language?
Select
Yes
No
Have you completed any behavioral intervention training?
Select
Yes
No
If yes, describe:
Are you presently licensed by DHHS to provide Foster Care?
Select
Yes
No
If yes, License #
Do you plan to provide care in your own home?
Select
Yes
No
Do you have other adults living in your home?
Select
Yes
No
If yes to the last two questions, you will need to provide background information regarding other adults in your home.
Have you ever been excluded from providing services due to fraud?
Select
Yes
No
Have you ever been the subject of an investigation of abuse or neglect?
Select
Yes
No
If yes, what was the outcome?
BACKGROUND AND INTERESTS
(Continued)
Have any other adults living in your home ever been the subject of an investigation of abuse or neglect?
Select
Yes
No
If yes, what was the outcome?
Do you have children?
Select
Yes
No
Are your children currently living in your home?
Select
Yes
No
Are you willing to provide transportation for children?
Select
Yes
No
If yes, you are required by State law to maintain auto insurance on your registered vehicle. The Respite Program recommends that you also maintain homeowner's or renter's insurance if you are providing respite care in your home. Please submit a copy of your drivers license.
With what age children would you like to work?
Do you smoke or does anyone in your home smoke?
Select
Yes
No
Do you have pets?
Select
Yes
No
If yes, describe:
Would you provide respite in a home where there are pets?
Select
Yes
No
Thank you for completing the Respite For ME "Online Request For Certification Form". Please click on the Submit Button and then Contact your Regional Respite Agency to schedule an Orientation
Please enter the word 'respite' here:
Thank you for requesting certification.
A representative will be in touch with you shortly.