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 (Employer) First and Last Name * Participant's (Employer) First and Last Name First First Last Last Participant's Regional Center * Email of Individual Completing Form * Direct Care Worker's (Employee) First and Last Name * Direct Care Worker's (Employee) First and Last Name First First Last Last Direct Care Worker's (Employee) Email * Direct Care Worker's (Employee) Phone Number * What is the relationship of the Direct Care Worker (Employee) to the Participant (Employer)? * Daughter/SonEx-SpouseFriendGrandchildGrandparentNeighborParentSiblingSpouseStepchildStepparentWorkerOther What is the relationship of the Direct Care Worker (Employee) to the Participant (Employer)? Has the Direct Care Worker (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 Worker (Employee) to drive the Participant (Employer). * Yes No I plan for this Direct Care Worker (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 Direct Care Worker (Employee) provides personal care to the Participant (Employer), they must provide their CPR/First Aide Training Certificate. Proof of Valid Licensure and Automobile Insurance * I acknowledge that if my Direct Care Worker (Employee) drives the Participant (Employer), 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.
