Home Care Provider Form

Early Support Services - child playing with toys

PLEASE NOTE - Community Bridges can only enter into agreements with potential home care providers living in our service area of Merrimack County, NH. Our service area includes the following areas: Allenstown, Andover, Boscawen, Bow, Bradford, Canterbury, Chichester, Concord, Danbury, Deering, Dunbarton, Epsom, Franklin, Henniker, Hill, Hillsborough, Hopkinton, Loudon, Newbury, New London, Northfield, Pembroke, Pittsfield, Salisbury, Sutton, Warner, Weare, Webster, Wilmot, and Windsor.

Personal

References - Please provide the names, addresses, telephone numbers, and email addresses of three (3) references unrelated to you that Community Bridges can contact.

Education

Personal Questionnaire

Please list three (3) expierences, skills or abilities relative to this position.

Currently, who makes up your household? Check all that apply.

Spouse

Children

Extended Family

Pets

Other

An answer of `Yes` to the following question will not necessarily disqualify you from being a home care provider. If there is a single offense on your record or anyone in your household`s record that is ten (10) or more years old there may be the possibility of a waiver if it is approved by the individual being serviced (or individual`s guardian, if applicable) and Community Bridges.

Please Note - A negative Tuberculosis test (TB Test) is required for this role.

I certify that all of the information that I provide on this Home Care Provider Form, or in any interview, or application, will be complete, true, and accurate. I understand that a home care provider is an independent contractor position and I will be neither an employee or agent of Community Bridges.

Thank you for completing the Home Care Provider Form. A member of our team will contact you.

Thank you for your interest in becoming a Home Care Provider. Someone will be in touch. In the meantime, if you have any questions please contact April Samenfeld by emailing asamenfeld@ccinnh.org