Registry Availability Update
First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Last 6 numbers of Social Security Number: *
Your answer
E-mail address:
Your answer
Zip Code: *
Your answer
1) List a current phone number where Consumers can call you for work. *
Include area code and phone number. Numbers ONLY.
Your answer
2) Are you available to accept work from NEW Consumers? *
3) If you answered No in question 2, type the names of any IHSS Consumers you are currently working with.
Include the first and last names of each Consumer.
Your answer
4) Check the days and times you are available to accept work for NEW Consumers. *
Check all that apply.
5) How many hours a week are you available to work for IHSS Consumers? *
6) How many miles are you willing to drive or commute from your home to work for a Consumer? *
7) Do you have a car that can be used when working with Consumers?
***Remember that you should be the only person driving the Consumer. You cannot ask another person to drive the Consumer on your behalf.
8) If your address has changed, please update it in the space below.
Example: 123 Main St. Apt. 1, San Diego, CA 12345
Your answer
By typing my name below, I certify that the above information is to the best of my knowledge, true and complete. I understand that any false information may eliminate me from being on the Registry. *
Type your first and last name below.
Your answer
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