ULTCW

Homecare Exchange
Application Form for Providers
(You can also submit your application online at HomeCareExchange.org, or by calling: 1-866-544-5742)

NAME

EMAIL
ADDRESS

CITY STATE

ZIP
CELL PHONE HOME PHONE

social security # CA ID / DRIVER’S LICENSE #

GENDER: ____FEMALE ____MALE DATE OF BIRTH (OPTIONAL) ______/______/______

What languages do you speak?

Primary Secondary Other

Please check the tasks you are capable of and willing to perform for the care recipient:

Accompany to Dr. appoint. Feeding Service Animals

Ambulation Exercises Grooming Shopping
Bathing Heavy Cleaning Wheelchair Assistance
Bed Baths Ironing
Bowel and Bladder Care Laundry
Bowel Program Medication Dispensation
Cleaning Menstrual Care
Cooking Prosthetic Assistance
Dressing Protective Supervision
Errands Repositioning and Skin Care
Any experience and/or training in the following? Please check all that apply.

Alzheimer’s Disease Mental / Emotional Disability

Arthritis Multiple Sclerosis
Asthma Paralysis
Cancer Parkinson’s Disease
Certified Nurse’s Aide Range of Motion
CPR Respiration Assistance
Dementia Registered Nurse
Diabetes Seizures
Feeding Tubes Special Diet
First Aid Spinal Bifida
Heart Condition Spinal Cord Injury
Home Health Aide Stroke
HIV/AIDS Thalamic Brain Injury
Hypertension Visual Impairment
Homecare Worker Training Vital Signs
Insulin care Wound Care
Licensed Vocational Nurse

Are you willing to avoid using scented fragrances on the job? Yes No
Are you willing to work for a care recipient with a dog? Yes No
Are you willing to work for a care recipient with a cat? Yes No
Are you willing to work at a home where there is a smoker? Yes No
Are you willing to comply with a no-smoking rule at your care recipient’s home? Yes No

How many hours are you currently working? per month.

How many additional IHSS hours do you wish to work? per month.
Would you be willing to work for a non-IHSS (private pay) client? Yes No
Do you have a car that can be used for work? Yes No
TIMES OF AVAILABILITY
Check the days and times when you might be willing to schedule services by entering a “ YES ”
or “ NO ” where applicable.

Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

Morning

Afternoon

Evening

Overnight

Live-in

On-call

Will you be available to work in an emergency or on call? Yes No

Educational Background
(Write highest level reached/subject area within each category)
Grade School Middle School
College Major

Personal References (Do not include relatives)

Name

Address
Primary phone

What is your relationship to this person?

Name

Address

Primary phone

What is your relationship to this person?

Homecare Employment History
Please list below each care recipient you have worked for within the last three years.

Name of care recipient

Date: From To

Reason for ending service

Phone number of care recipient (if available)

(If care recipient not available) Name and phone number of recipient family member:

Name of care recipient

Date: From To

Reason for ending service

Phone number of care recipient (if available)

(If care recipient not available) Name and phone number of recipient family member:

Name of care recipient

Date: From To

Reason for ending service

Phone number of care recipient (if available)

(If care recipient not available) Name and phone number of recipient family member:

Name of care recipient

Date: From To

Reason for ending service

Phone number of care recipient (if available)

(If care recipient not available) Name and phone number of recipient family member:
Name of care recipient

Date: From To

Reason for ending service

Phone number of care recipient (if available)

(If care recipient not available) Name and phone number of recipient family member:

I certify under penalty of perjury that the information provided above is true to the best of my
knowledge. I also understand that any misrepresentation on my part may result in disqualification
or removal from the Homecare Exchange at any time. I further authorize the Homecare Exchange
and/or the care recipient to contact the above employers and references concerning my work
and character.

Signature Date

IMPORTANT You must submit the following documents along with your application. If you do not
submit all the following documents, we cannot process your application.

1) Photocopy of the letter from the Personal Assistance Service Council (PASC) stating either
that you passed your background check; or that you are not required to undergo a new
background check.

2) Photocopy of your California driver’s license or identification card

3) Photocopy of your social security card

4) Photocopy of a check stub with a deduction for union dues 

FOR OFFICE USE ONLY

Participant’s Right, Responsibilities and Release Form signed and received? Yes No
Date Processed By
Employment History checked by Date
References checked by Date

PLEASE READ CAREFULLY

PARTICIPANT’S RIGHTS, RESPONSIBILITIES AND RELEASE

Note: This Agreement contains important provisions regarding the nature of Homecare Exchange
services, the Independent Provider Mode, the duties of Homecare Exchange participants, and the
Release of the Homecare Exchange, its affiliates and agents from any liability.

Homecare Exchange
1. Nature of Homecare Exchange Services: SEIU, The United Long-Term Care Workers’ Union,
Provides this Union Provider Homecare Exchange at no cost to the Provider or Care recipient, for the
express purpose of facilitating and/or assisting in the development of the employment relationship
between the Provider and potential Care recipient. However, the decision of whether to employ any
potential Provider applicant is solely at the discretion and control of the Care recipient. Homecare
Exchange services are entirely optional and voluntary. The Homecare Exchange shall require that
all Provider applicants comply with all state laws and regulations required for their services as a
Provider (including all required background checks). However, the Homecare Exchange is not
responsible for any further or independent verification of whether the Provider has actually met all
the conditions, beyond the normal presentation of documents indicating that such requirements
have indeed been met. Beyond this initial screening process, the Homecare Exchange does not
perform any additional evaluation, interviews, or other means of verify or vouching for the quality of
the Provider Homecare Exchange applicant. Therefore, it is essential that the Care recipient conduct
his/her own evaluation of the Provider prior to establishing the employment relationship. Further, the
Homecare Exchange does not warrant the quality of the applicant or his or her abilities to carry out
the duties required by the Care recipient. The Homecare Exchange will, however, conduct some
limited matching of the Provider to the stated needs of the Care recipient profile. Any Care recipient
and applicant Provider therefore must use their own judgment and make their own decisions
regarding one another’s skills, character and compatibility, and as to how well they may meet each
other’s needs. The Care recipient and Provider assume and accept the risk of such decisions.

2. Independent Provider Mode of Service: When a Care recipient offers employment to a Provider,
and the Provider has accepted such employment the Provider becomes the Care recipient’s
employee. In accordance with the law and County DPSS requirements and guidelines, the Care
recipient has sole authority to hire, assign hours and duties, direct the work, supervise, evaluate,
and choose whether to continue or terminate the Provider’s services. Likewise, the Provider retains
the right to resign such employment at any time without notice or cause. The Homecare Exchange
has no authority or responsibility for any such matters or for any injuries or damages which may arise
out of the referral or which may arise out of the employment, or for investigating or resolving any
disputes, misunderstandings or injuries which may arise between a Care recipient and a Provider or
any third party.

RIGHTS, RESPONSIBILITIES AND RELEASE ( 3 )

Receipt and Use of Personal Information. As part of its operations, the Homecare Exchange may
seek and/or receive information concerning Homecare Exchange participants, including information
furnished by the Care recipient about his or her needs, or employment and personal information
from references (or others) of a confidential or sensitive nature. The Homecare Exchange may share
such information with others for Homecare Exchange purposes, or investigate or act upon such
information to grant or deny referrals, or to suspend, exclude or remove a Provider or Care recipient
from Homecare Exchange participation, through confidential procedures. Any disputes concerning
any such uses or related decisions are to be determined by the Homecare Exchange Management
Committee. The decisions of the Homecare Exchange Management Committee are final and binding
upon all concerned, including Homecare Exchange staff and any involved Care recipient (s) and/or
Provider(s), and are not to be the subject of any further proceedings or litigation of any nature.

6. Participant Responsibilities: Homecare Exchange participant and services are a revocable

privilege and not a right. The Homecare Exchange Management Committee can terminate the
participation of any Provider or Care recipient at any time it deems appropriate and necessary.
Each participant (Provider or Care recipient) is expected and required, as an ongoing condition of
Homecare Exchange participation:

(a) To comply with all Homecare Exchange policies, procedures and directives, and to cooperate
fully with Homecare Exchange personnel;
(b) To pursue all referrals diligently, by prompt follow-up, to attend all agreed upon interviews and
other appointments, and to keep the Homecare Exchange updated as to all decisions; and
(c ) To treat Homecare Exchange staff and all other Homecare Exchange participants with civility
and respect.

PARTICIPANT’S RIGHTS, RESPONSIBILITIES AND RELEASE ( 4 )

PARTICIPANT’S RELEASE: The undersigned Homecare Exchange participant hereby releases the
Homecare Exchange from any claim, damages, injuries, liability or remedy of any nature relating in
any way to the Homecare Exchange, its services or denial of services, or its actions or failures to
act. This includes any injuries suffered while seeking employment or considering referrals, or while
providing or receiving home assistance services or acting as employer of Provider, the undersigned
will not make any claims (or seek any remedy) against the Homecare Exchange.

The above Release applies to, Homecare Exchange SEIU ULTCW, the County of Los Angeles,
affiliated agencies such as those furnishing emergency/respite services to Care recipients, the
individual officers, governing board members, agents, employees, representatives, advisers,
insurers and volunteers of the Homecare Exchange and of such related and affiliated entities, and
each of them, and all entities and persons who have furnished information or otherwise cooperated
with the Homecare Exchange. This Release is made on behalf of the undersigned participant’s
personal representatives, family, heirs, dependents, community property and assignees, as well as
on the participant’s own behalf.
 (c) Nothing in the above Release is intended to affect any rights or claims the undersigned may
have against a Provider or Care recipient, or against any person or entity other than those
Homecare Exchange-related ones described above.

(d) If the undersigned is a Provider applicant, this Release does not affect any rights he or she
may have either under the PASC-SEIU collective bargaining agreement or against the State of
California under Workers Compensation or Unemployment Insurance laws.

PARTICIPANT’S RIGHTS, RESPONSIBILITIES AND RELEASE ( 5 )

The undersigned has carefully reviewed and considered each and every one of the terms and
conditions of this Agreement, understands them, and has decided voluntarily to agree with them.
It is understood that the Homecare Exchange and its affiliates will rely upon this Agreement when
granting Homecare Exchange participation and services to the undersigned Homecare Exchange
participation.

Signature of Participant

Print Name of Participant

Date