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First name
*
Last name
*
Phone
Email
*
where are you located?
*
Select your region
What languages do you speak?
*
English
French
Other
Do you have access to reliable transportation?
*
Yes
No
Public transit only
Which services do you provide?
*
Personal care light (dressing, hair, etc)
Personal care heavy (showers, toileting, etc)
Lifts/transfers
Medication
Companionship
Overnight support
Pet care
Cooking
Housekeeping light
Housekeeping heavy
Out-Trips (grocery shopping, etc.)
Odd jobs
Dog Walking
Gardening/lawn maintenance
Other
What is your general availability?
*
are you open to short-notice shifts?
*
Yes
No
Occasionally
Years of experience in care or support services
*
>1 year
1-3 years
4-7 years
8+ years
What certifications do you currently hold?
*
PSW certificate
FA / CPR
DSW diploma
Nursing
Mental health first aid
High5
Other
What age groups do you feel comfortable working with?
*
Children (under 12)
Teens
Adults
Seniors
Are you experienced working with clients with physical disabilities?
*
Yes
No
are there any situations or demographics that you are not comfortable working with?
*
Are you interested in being scheduled for shifts through Helperly?
*
Yes
No
Maybe
would you like to be matched with recurring clients or one-time requests?
*
Recurring
One-time
Open to both
Do you have any notes, requests accommodations, etc. you would like us to know about?
*
what are your hopes from participating in the Helperly pilot?
*
Do you consent to Helperly collecting and using the information provided for the purpose of matching you with service providers?
Yes
No
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