SequoiaSD Employee Request Form SequoiaSD Employee Request Form Please fill out this form to begin the hiring process. SequoiaSD will reach out to each potential employee to begin the New Hire Process within two business days of receiving this form. Participant's First and Last Name * Participant's First and Last Name First First Last Last Participant's Regional Center * Email of Individual Completing Form * Direct Care Professional's (Employee) First and Last Name * Direct Care Professional's (Employee) First and Last Name First First Last Last Direct Care Professional's (Employee) Email * Direct Care Professional's (Employee) Phone Number * What is the relationship of the employee to the participant? * Daughter/SonEx-SpouseFriendGrandchildGrandparentNeighborParentSiblingSpouseStepchildStepparentWorkerOther What is the relationship of the employee to the participant? Has the Direct Care Professional (Employee) completed a Live Scan with another FMS company? * Yes No Service Code * Respite Community Living Support Community Integration Support Employment Support OtherOther I plan for this Direct Care Professional (Employee) to drive the participant. * Yes No I plan for this Direct Care Professional (Employee) to provide personal care to the participant (bathing, toileting, feeding, etc.) * Yes No Pay Rate per Hour * $ Signature (please type your first and last name) * Date * Proof of CPR/First Aide Certification * I acknowledge that if my employee provides personal care to the participant, they must provide their CPR/First Aide Training Certificate. Proof of Valid Licensure and Automobile Insurance * I acknowledge that if my employee drives the participant, they must always submit and maintain a valid Driver’s License and Proof of Automobile Insurance. Demonstrated Experience * I acknowledge that this individual has demonstrated experience successfully providing this or similar services or demonstrated life experiences and skills to provide this service. Submit If you are human, leave this field blank.
