AFL Caregiver Application

AFL Direct Care Provider Application
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you resided in the address provided above for more than 3 years?*

YesNo
If no, type the address lived in prior to current
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Birth 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 with Emerest before?

YesNo
Please select the dates enrolled
Have you been convicted of a felony in the last 7 years? (Conviction will not necessarily disqualify applicant from participation)*

YesNo
If yes, please explain:
Bilingual?*

YesNo
Primary Language
Secondary Language
If you selected other please list below:
Name of employer/participant (family member) you will be caring for?*

First NameLast Name
What is your relationship to the employer/participant (family member) you will be caring for?*
Please take a live photo of yourself for your provider profile. (Please do not upload a picture of your ID here)*

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
File Upload

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
File Upload

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
File Upload

Cancelof

Back-Up Direct Care Provider Contact Information

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

First NameLast Name
Relationship
Cell Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Notify in Case of Emergency #2:
Back-Up Contact Name #2*

First NameLast Name
Relationship
Cell Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Enrollment 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
Date
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 Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Have you been convicted of any crime? (If yes please explain below)*

YesNo
If yes, please explain:
Have you been convicted of a crime involving violence or dishonesty in a state court or federal court in any state or were you subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a Unites States possession or territory or a foreign jurisdiction?*

YesNo
Present Employer
Position
Supervisor's Name
Supervisor's Phone
Please enter a valid phone number.
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone
Please enter a valid phone number.
Disclosure Regarding Background Investigations On You

As required by DSS, Emerest Home Care of Connecticut LLC ("the Company") may obtain "consumer reports" about you from a consumer reporting agency for employment purposes. A "consumer report" is a background screening report that contain information regarding your criminal history, sex offender registry status, credit history, employment history, education history, social media activity, driving history, drug test results, professional licenses, and other information about you. It may bear upon your character, general reputation, personal characteristics and/or mode of living.

AUTHORIZATION REGARDING BACKGROUND INVESTIGATION

By signing below, I acknowledge receipt of the following separate documents (and
certify that I have read and understood them):
• DISCLOSURE REGARDING BACKGROUND INVESTIGATION ON YOU;
• A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT; •ADDITIONAL NOTICE REGARDING INVESTIGATIVE CONSUMER REPORTS
ON YOU;
• ADDITIONAL STATE LAW NOTICES.
By signing below, I authorize Emerest Home Care of Connecticut LLC
(“the Company”) to obtain “consumer reports” and “investigative consumer reports” about me for employment purposes at any time during the hiring process and throughout my employment, if applicable.

ADDITIONAL NOTICE REGARDING INVESTIGATIVE CONSUMER REPORTS ON YOU

Emerest Home Care of Connecticut LLC (“the Company”) may also
request an “investigative consumer report” on you from a consumer reporting agency. An “investigative consumer report” is a background screening report generated through personal interviews with sources such as your neighbors, friends, or associates. The consumer reporting agency that may prepare an “investigative consumer report” on you for the Company is Sapphire Check LLC, 117 Ditmas Avenue, Brooklyn, NY 11218, 888-993-4473. The information contained in an “investigative consumer report” may bear upon your character, general reputation, personal characteristics, and/or mode of living.
Please be advised that the nature and scope of the most common form of “investigative consumer report” that may be ordered by the Company is an investigation into your employment history. During such an investigation, Sapphire Check LLC may askquestions about your employment history to certain knowledgeable individuals and provide response information to the Company. Note: You have the right to request additional information regarding the nature and scope of any “investigative consumer report” ordered by the Company on you. You may do so by contacting the Company.

Applicant’s Statement

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.

I/We declare that all information given in this application is true and correct. I/We authorize Sapphire Background Check on behalf of the employer to verify and obtain a complete consumer Credit report, Driving records, Criminal records and Employment verification, and supply information obtained to their clients. This information is not privileged. This authorization shall be valid in original or fax copy form.
Date*

MonthDayYear
Date
Signature*

Clear

DIRECT CARE PROVIDER CONSENT TO EMEREST DISCLOSURE TO PARTICIPANT/EMPLOYER OF CRIMINAL BACKGROUND
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.
By clicking this box, I consent to Emerest sharing with the participant/employer information Emerest obtains from the criminal background check.*
By clicking this box, I DO NOT consent to Emerest sharing with the participant/employer information Emerest obtains from the criminal background check.*
Direct Care Provider Signature*

Clear
Date Signed by Direct Care Provider*

MonthDayYear
Date

Training Videos

HIPAA/Universal Precautions/Elder Abuse
AFL TRAINING ACKNOWLEDGEMENT

My signature below acknowledges that I fully understand the above trainings offered to me.

HIPAA / UNIVERSAL PRECAUTIONS/ ELDER ABUSE

If I have any further questions or are in need of any further training, it is my responsibility to inform Emerest. At that time, the AFL Administrative department will schedule a day/time for additional training to be completed in office or at home via a Registered Nurse. In the event that I am not understanding or demonstrating full confidence and knowledge in my performance to any of the above trainings, Emerest will determine if additional training is needed.

Failure to comply will result in disciplinary action, which may include removal/discharge from the AFL program.
Name*

First NameLast Name
Date

MonthDayYear
Date
Signature*

Clear

ACKNOWLEDGEMENT OF RECEIPT OF THE EMEREST AFL POLICY AND PROCEDURE HANDBOOK
A copy of this manual will be emailed to you when you submit this form
Statement of Disclaimer-7.2

Neither this handbook nor any Emerest Home Care of Connecticut LLC communication or practice creates an employment contract for any length of time. No unauthorized DCP or representative of Emerest has any power to enter a written direct care provider arrangement.

ACKNOWLEDGEMENT OF RECEIPT OF THE EMEREST HOME CARE OF CONNECTICUT LLC-AFL HANDBOOK

I have received and read the AFL handbook, had an opportunity to ask questions about it and I am familiar with its terms and conditions. I specifically understand:

1. The handbook does not create a participation contract between the company and me but is merely a set of general guidelines for the implementation of AFL policies. I understand that no representative of the company, other than the Administrator, has the authority to modify any provision of the handbook or enter any contract for participation or to make any agreement contrary to the policies in this handbook.

2. I will seek clarification from my case coordinator if there is any policy or provision in the handbook that I do not understand.

3. I also understand that these policies and procedures are continually evaluated and may be amended, modified, or terminated at any
time.
Name*

First NameLast Name
Date

MonthDayYear
Date
Signature*

Clear
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Should be Empty:

AFL Direct Care Provider Application

ID Upload

Social Security Card Upload

Proof of Address Upload

Back-Up Direct Care Provider Contact Information

Notify in Case of Emergency #1:

Notify in Case of Emergency #2:

Enrollment Background Check Consent

DIRECT CARE PROVIDER CONSENT TO EMEREST DISCLOSURE TO PARTICIPANT/EMPLOYER OF CRIMINAL BACKGROUND

Training Videos

ACKNOWLEDGEMENT OF RECEIPT OF THE EMEREST AFL POLICY AND PROCEDURE HANDBOOK