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Respite Worker Registration Package (For office use only) FM ID: ________ IN ID: ________ RESPITE WORKER REGISTRATION PACKAGE Respite Worker Information Name: __________________________________________________________________________ Address: ________________________________________________ Apt/Unit: ____________ City: ______________________________ Postal Code: ________________________ Main Intersection: _________________________________________________________________ Telephone: _____________________________ Other: _____________________________ Email: ___________________________________________________________________________ Male/Female/Other: _________ Community Region: (where you live) Antigonish County - Antigonish Antigonish County - Monastery Antigonish County - St. Andrews Antigonish County - Tracadie Colchester County - Bible Hill Colchester County - Millbrook Colchester County - Stewiake Colchester County - Tatamagouche Colchester County - Truro Cumberland County - Amherst Cumberland County - Oxford Cumberland County - Parrsboro Cumberland County - Pugwash Cumberland County - Springhill Cumberland County - Wentworth East Hants - Elmsdale East Hants - Enfield East Hants - Indian Brook East Hants - Mount Uniacke East Hants - Shubenacadie Guysborough County - Canso Guysborough County - Cross Roads Country Harbour Guysborough County - Guysborough Guysborough County - Mulgrave Guysborough County - Sherbrooke Pictou County - Hopewell Pictou County - Little Harbour Pictou County - Merigomish Pictou County - New Glasgow Pictou County - Pictou Pictou County - Pictou Landing Pictou County - River John Pictou County - Scotsburn Pictou County - Stellarton Pictou County - Thorburn Pictou County - Trenton Pictou County - Westville Hosted by Highland Community Residential Services PO Box 2140, 276 Foord Street, Stellarton, Nova Scotia B0K 1S0 Attn: Amanda Smith-Robinson - Respite Coordinator respiteservices.com is committed to protecting the privacy, confidentiality and security of your personal information. We respect your privacy and adhere to all legislative requirements. We do not rent, sell or trade our mailing lists. The information you provide to us will be used to connect you to suitable families, keep you informed about our activities and other respite opportunities or training and to send update forms. Please visit our website www.respiteservices.com for a complete version of our Privacy Statement, Privacy Policy and Terms of Use. Privacy policy: https://www.respiteservices.com/Ontario/index.aspx?ArticleID=1914&lang=en-CA Terms of Use: https://www.respiteservices.com/Ontario/index.aspx?ArticleID=1719&lang=en-CA (For office use only) FM ID: ________ IN ID: ________ RESPITE WORKER REGISTRATION PACKAGE Qualifications Occupation: ___________________________________________________________________________________ Education/Training: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please indicate the areas where you have experience: 22q13.3 Disorder Impulse Control and Addiction Disorders Acquired Brain Injury Intellectual Disability Aggressive Behaviours Learning Disabilities Allergies Lou Gehrig’s disease (ALS) Alzheimer Disease Mental Health Anxiety Disorders Mood Disorders Arthritis Multiple Sclerosis (MS) Asperger Syndrome Muscular Dystrophy (MD) Asthma Neuro-muscular Disorders Attention Deficit Disorder (ADD) Obsessive Compulsive Disorder (OCD) Attention Deficit Hyper Disorder (ADHD) Oppositional Defiant Disorder (ODD) Autism Spectrum Disorder Other Cancer Palliative Cerebral Palsy (CP) Paralysis Challenging Behaviours Parkinson Disease Challenging Sexual Behaviours Personality Disorders Chronic Illnesses Physical Disability Complex Medical Issues Post-Traumatic Stress Disorder (PTSD) Dementia/Cognitive Impairment Prevention and Management of Aggressive Developmental Disability Behaviour (PMAB) Diabetes Psychotic Disorders Dissociative Disorders Seizures Down Syndrome Somatic Symptom Disorders Dual Diagnosis Stress Response Syndromes Eating Disorders Stroke Fetal Alcohol Syndrome (FAS) Swallowing Difficulties Food Avoidance Emotional Disorder (FAED) Tic Disorders Frail/Elderly Tuberculosis (TB) Hearing Impairment Visual Impairment Heart Disease Skills: Not Applicable Insulin Injections Catheterization Oxygen Central Line (CVC) Suctioning Colostomy Care TPN Feeding Epi Pen Tracheotomy G/J Tube Ventilator Glucose Monitoring Inhalation Therapy Hosted by Highland Community Residential Services PO Box 2140, 276 Foord Street, Stellarton, Nova Scotia B0K 1S0 Attn: Amanda Smith-Robinson - Respite Coordinator respiteservices.com is committed to protecting the privacy, confidentiality and security of your personal information. We respect your privacy and adhere to all legislative requirements. We do not rent, sell or trade our mailing lists. The information you provide to us will be used to connect you to suitable families, keep you informed about our activities and other respite opportunities or training and to send update forms. Please visit our website www.respiteservices.com for a complete version of our Privacy Statement, Privacy Policy and Terms of Use. Privacy policy: https://www.respiteservices.com/Ontario/index.aspx?ArticleID=1914&lang=en-CA Terms of Use: https://www.respiteservices.com/Ontario/index.aspx?ArticleID=1719&lang=en-CA (For office use only) FM ID: ________ IN ID: ________ RESPITE WORKER REGISTRATION PACKAGE Types of Support: Not Applicable Job Support Alternative Communication Devices Life Skills Applied Behaviour Analysis/Intensive Lift/Transfers Behavioural Intervention (ABA/IBI) Meal Preparation Approved Alternative Family Support Provider Medical Appointments/Other Medical Support Assistive Communication (i.e. PECS) Medication Administration Assistive Devices (wheelchair, etc.) Medication Management Behavioural Mobility Camp Companion NCI/SMG Cardio Pulmonary Resuscitation (CPR) Nursing Community Integration Oral Feeding CPI/NVCI Personal Care (toileting) CPR Physical (transfers & lifts) Crisis Prevention & Intervention (CPI) Physio/Occupational Therapy Family Home/Associate Living Sensory Integration First Aid Sign Language Host Home Social Network Building In a Respite Apartment Speech & Language / Communication In the Community Sports In the Individual's Home Transportation Intensive Behavioural Intervention Tutoring First Aid Expiry Date: ___________________ CPR Expiry Date: ___________________ Crisis Prevention Intervention Expiry Date: ___________________ Other Experience: _____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ What languages do you speak in addition to English? __________________________________________________ _____________________________________________________________________________________________ Do you have a Driver’s License? Yes No Are you willing/able to use your own vehicle during respite support? Yes No Please list your interest/hobbies: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Hosted by Highland Community Residential Services PO Box 2140, 276 Foord Street, Stellarton, Nova Scotia B0K 1S0 Attn: Amanda Smith-Robinson - Respite Coordinator respiteservices.com is committed to protecting the privacy, confidentiality and security of your personal information. We respect your privacy and adhere to all legislative requirements. We do not rent, sell or trade our mailing lists. The information you provide to us will be used to connect you to suitable families, keep you informed about our activities and other respite opportunities or training and to send update forms. Please visit our website www.respiteservices.com for a complete version of our Privacy Statement, Privacy Policy and Terms of Use. Privacy policy: https://www.respiteservices.com/Ontario/index.aspx?ArticleID=1914&lang=en-CA Terms of Use: https://www.respiteservices.com/Ontario/index.aspx?ArticleID=1719&lang=en-CA (For office use only) FM ID: ________ IN ID: ________ RESPITE WORKER REGISTRATION PACKAGE Do you have additional special skills and/or strengths? ________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
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