Online Provider Application Form
Please use this form to apply for a provider position at A Brighter Avenue. An administrator will contact you once your application is received and processed.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Who can we thank for referring you?
*
We like to make sure our providers and families get a "thank you" bonus when connecting us to quality applicants like yourself! Please let us know who to thank. (If you found us online or some other independent way, just put "N/A"!)
Are you at least 18 years old?
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Major Cross Streets
*
Please choose one:
*
I already have a client or clients I plan to work with and don't need anyone new
I have a client or clients to work with but I also want an additional client
I do not have an existing client and need to interview for one or more
Name of your existing client(s)
Schedule Requested
*
Services to provide (check all that apply)
*
Habilitation (working on a client's goals and taking data)
Attendant Care (going through a checklist of self-care tasks with a client)
Respite (entertaining and caring for a client to give the parent/guardian a break)
Please indicate your level of experience
*
New to the field but willing to learn!
6 months - 2 years experience with special needs
2 - 5 years experience with special needs
5 + years experience with special needs
Do you have 2+ years experience in any of these categories?
*
Experience with autism
Experience with young kiddos
Experience with teenagers
Experience with adults
None yet
Please tell us about your experience or interests in the field
*
Highest diploma or degree and field of study
*
Name of School or Institution
*
Are you bilingual?
*
Yes
No
Please list second language
Please check any certifications you already have
*
CPR
First Aid
Article IX
Class 1 Fingerprint Clearance Card
Direct Care Working Training (required for Attendant Care)
Habilitation Training
Habilitation Experience
No trainings or certifications yet
Name of current company, if applicable
Employment dates
Reason for seeking other employment
Anticipated start date
-
Month
-
Day
Year
Date
Please list a reference we can call and email
*
First Name
Last Name
What type of acquaintance is this?
*
Supervisor
Co-Worker
Friend
Length of time you've known this person
*
Their Phone Number
*
Please let them know to expect our call and email. We cannot proceed with your application until we make contact with each reference.
Format: (000) 000-0000.
Their Email
*
example@example.com
Second Reference
*
First Name
Last Name
Type of acquaintance
*
Supervisor
Co-Worker
Friend
Length of time you've known this person
*
Their Phone Number
*
Please let them know to expect our call and email. We cannot proceed with your application until we make contact with each reference.
Format: (000) 000-0000.
Their Email
*
example@example.com
Third Reference
*
First Name
Last Name
Type of acquaintance
*
Supervisor
Co-Worker
Friend
Their Phone Number
*
Please let them know to expect our call and email. We cannot proceed with your application until we make contact with each reference.
Format: (000) 000-0000.
Their Email
*
example@example.com
Thank you for your interest in working with us!
You will hear from an administrator soon.
Submit
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