AFL Caregiver Application

Direct Care Provider Application
Name

First NameLast Name
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Have you lived at this address for more than 3 years?
Previous Address
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearBirth Date
Social Security Number
Please note Emerest takes all necessary precautions to protect your SSN and all other personal information
Have you ever been enrolled in the AFL program before?
Please select the dates enrolled
Have you been convicted of a felony in the last 7 years?
If yes, please explain.
Are you bilingual?
Primary Language
Secondary Language
If other, please specify.
Name of Person You Will Care For

First NameLast Name
Relationship to Person You Will Care For
Direct Care Provider Profile Photo (Take A Selfie or Upload A Photo)
Photo ID Upload

Emerest requires copies of your ID. Please upload a picture of it here. You can take a photo of it or upload a photo from your phone or device below.
Take Photo
Upload File

Cancelof
Before proceeding please be sure you have uploaded a copy of your ID.

Social Security Card Upload

Emerest requires a copy of your social security card. Please upload a picture of it here. You can take a photo of it OR upload a photo from your phone or device below.
Take Photo
Upload File

Cancelof
Before proceeding please be sure you have uploaded a copy of your social security card.

Proof of Address Upload
DSS requires Emerest ensure that the direct care provider reside with their employer. As a result, please provide proof of address per the below:

The following list is acceptable for documentation:
1. Computer-generated bill or statement from a bank or mortgage company. utility company, or other creditor delivered to that address by the U.S. Postal Service.
2. Current valid homeowner's, renters or motor vehicle insurance policy dated within the last year.
3. Current motor vehicle loan statement for a motor vehicle registered in your name.
4. Motor vehicle registration
5. Driver's license
6. Residential mortgage, lease or rental contract showing signatures from all parties needed to execute the agreement and dated within the last year.
Please upload a picture of it here. You can take a photo of it OR upload a photo from your phone or device below.
Take Photo
Upload File

Cancelof

Emergency Contacts

Emerest requires to have 2 back-up direct care providers on file in case of emergency.
Emergency Contact #1
Back-Up Contact Name #1

First NameLast Name
Relationship
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2
Back-Up Contact Name #2

First NameLast Name
Relationship
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Background Check Consent
We have retained SappHire Check to conduct criminal background checks on our behalf. SappHire will send you an email from Support@sapphirecheck.com or a text message from 877-232-3945 for you to complete the background check form. Please complete the form as quickly as possible so that the hiring process can proceed without delay. Please note that when completing the background check submission form you will be asked to certify that the statements you make on the application are true and complete to the best of your knowledge and are made in good faith, and that you understand that if you knowingly make any misstatements of fact, you are subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Please note Emerest takes all necessary precautions to protect your SSN and all other personal information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Have you been convicted of any crime?
If yes, please explain.
Have you been convicted of a crime involving violence or dishonesty?
Current Employer
Position
Supervisor Name
Supervisor Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Background Check Disclosure
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature

Background Check Consent for Participant/Employer
Participant/Employer Name

First NameLast Name
Direct Care Provider Name

First NameLast Name
The participant/employer named above requested that Emerest Home Care of Connecticut LLC conduct a criminal background check on you as part of the participant/employer’s participation in the Adult Family Living Program.

Please check the box below indicating whether you consent to Emerest sharing with the participant/employer information Emerest obtains from the criminal background check.

Note: Your consent to Emerest sharing with the participant/employer information Emerest obtains from the criminal background check is a condition of you being a DCP.
I consent to sharing the background check with the participant/employer.
I do not consent to sharing the background check with the participant/employer.
Direct Care Provider Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Training Videos

HIPAA/Universal Precautions/Elder Abuse
Training Video
Training Acknowledgment
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature

Acknowledgment of Receipt of the AFL Policy and Procedure Handbook
A copy of this manual will be emailed to you when you submit this form
Policy Acknowledgment
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
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Should be Empty:

Direct Care Provider Application

Photo ID Upload

Social Security Card Upload

Proof of Address Upload

Emergency Contacts

Emergency Contact #1

Emergency Contact #2

Background Check Consent

Background Check Consent for Participant/Employer

Training Videos

Acknowledgment of Receipt of the AFL Policy and Procedure Handbook