Step 1: Respite Provider Application

Application Information

First Name

Middle Name

Last Name

Date of Birth

Address

City

State

Zip

Phone

How many years of experience do you have?

Experience working with 0-3 years old

Experience working with 3-6 years old

Experience working with 7-10 years old

Experience working with 10-12 years old

Experience working with 13+ years old

Are you a citizen of the United States?

If no, are you authorized to work in the U.S.

Are you currently certified in CPR/First Aid?

If yes, when does your certificate expire?

Have you ever been convicted of a felony?

If yes, explain

Who would you like to provide respite services for?

If you are open to providing care to community youth, please indicate which cities you'd prefer to work within.

Respite Youth's Information

If you are applying to provide care to specific youth(s), please complete the following information to the best of your ability in order for the Youth to be added to our system. If not, please proceed to the signature box.

Youth Information (1)

Youth 1: Full Name

Youth 1: DOB

Youth 1: Medicaid ID

Youth 1: Guardian's Full Name

Youth 1: Guardian's Phone Number

Youth 1: Care Coordinator's Full Name

Youth 1: Care Coordinator's Phone Number

Youth 1: Care Coordinator's Email

Youth 1: Is this youth receiving OhioRise care coordination through Unison Health?

Youth Information (2)

Youth 2: Full Name

Youth 2: DOB

Youth 2: Medicaid ID

Youth 2: Guardian's Full Name

Youth 2: Guardian's Phone Number

Youth 2: Care Coordinator's Full Name

Youth 2: Care Coordinator's Phone Number

Youth 2: Care Coordinator's Email

Youth 2: Is this youth receiving OhioRise care coordination through Unison Health?

Youth Information (3)

Youth 3: Full Name

Youth 3: DOB

Youth 3: Medicaid ID

Youth 3: Guardian's Full Name

Youth 3: Guardian's Phone Number

Youth 3: Care Coordinator's Full Name

Youth 3: Care Coordinator's Phone Number

Youth 3: Care Coordinator's Email

Youth 3: Is this youth receiving OhioRise care coordination through Unison Health?

Login Credentials

Username (Use Email Address)

Password

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Date