(For office use only) FM ID: ________ IN ID: ________ RSNS Worker Registration RSNS Worker Information First Name: _________________________ Last Name: _______________________ Initial: __ Address: ________________________________________________ Apt/Unit: ____________ City: ______________________________ Postal Code: ________________________ Nearest Intersection: ___________________________________________________________ Telephone: _________________________ Other: _____________________________ Email: _____________________________ Gender: Male Female Other Community Region: More information and maps: www.halifax.ca/municipalclerk/districtboundaries District 1: Waverly – Fall River – Musquodoboit Valley District 2: Preston – Chezzetcook – Eastern Shore District 3: Dartmouth South – Eastern Passage District 4: Cole Harbour – Westphal District 5: Dartmouth Centre District 6: Harbourview – Burnside – Dartmouth East District 7: Halifax South Downtown District 8: Halifax Peninsula North District 9: Halifax West Armdale District 10: Halifax – Bedford Basin West District 11: Spryfield – Sambro Loop – Prospect Road District 12: Timberlea – Beechville – Clayton Park West District 13: Hammonds Plains – St. Margarets District 14: Middle/Upper Sackville – Beaver Bank – Lucasville District 15: Lower Sackville District 16: Bedford – Wentworth 1 Hosted by Autism Nova Scotia 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. 5945 Spring Garden Road Halifax, NS B3H 1Y4 Attn: Melissa Myers Respite Coordinator (For office use only) FM ID: ________ IN ID: ________ Other Experience: Occupation:______________________________ Education/Training:________________________ Please indicate the areas where you have experience: 22q13.3 Disorder Learning Disabilities Acquired Brain Injury Lou Gehrig’s disease (ALS) Aggressive Behaviours Mental Health Allergies Mood Disorders Alzheimer Disease Multiple Sclerosis (MS) Anxiety Disorders Muscular Dystrophy (MD) Arthritis Neuro-muscular Disorders Asperger Syndrome Obsessive Compulsive Disorder Asthma (OCD) Attention Deficit Disorder (ADD) Oppositional Defiant Disorder Attention Deficit Hyper Disorder (ADHD) (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 Dementia/Cognitive Impairment (PTSD) Developmental Disability Prevention and Management of Diabetes Aggressive Behaviour Dissociative Disorders (PMAB) Down Syndrome Psychotic Disorders Dual Diagnosis Seizures Eating Disorders Somatic Symptom Disorders Factitious Disorder Stress Response Syndromes Fetal Alcohol Syndrome (FAS) Stroke Food Avoidance Emotional Disorder (FAED) Swallowing Difficulties Frail/Elderly Tic Disorders Hearing Impairment Tuberculosis (TB) Impulse Control and Addiction Disorders Visual Impairment 2 Hosted by Autism Nova Scotia 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. 5945 Spring Garden Road Halifax, NS B3H 1Y4 Attn: Melissa Myers Respite Coordinator (For office use only) FM ID: ________ IN ID: ________ Intellectual Disability Heart Disease Please indicate your experience with the following skills: Not Applicable Catheterization Colostomy Care Epi Pen G/J Tube Glucouse Monitoring Please indicate your experience in the following types of Support: TPN Feeding Not Applicable - Tracheotomy Alternative Communication Devices Ventilator Assistive Communication (i.e. PECS) Job Support Assistive Devices Life Skills Assistive Devices (wheelchair, etc.) Lift/Transfers Behaviour Management System Meal Preparation Behavioural Medical Appointments/Other Camp Companion Medical Support Community Integration Medication Administration CPI/NVCI Medication Management CPR Oral Feeding Crisis Prevention & Intervention (CPI) Other Family Home/Associate Living Personal Care (toileting) First Aid Physical (transfers & lifts) In a Respite Apartment Recreational Activities In the Community Sensory Integration In the Individual's Home Sign Language Job Coaching Social Network Building Inhalation Therapy Speech & Language / Oxygen Communication Suctioning Transportation 3 Hosted by Autism Nova Scotia 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. 5945 Spring Garden Road Halifax, NS B3H 1Y4 Attn: Melissa Myers Respite Coordinator (For office use only) FM ID: ________ IN ID: ________ First Aid Expiry Date:_____________ CPR Expiry Date:_____________ CPI 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: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Please list your interest/hobbies: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Additional Comments (restrictions, concerns, preferences, etc): ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Preferences: Are you willing to work with …? Any Male Female Other Preschoolers (0-5) School Aged (6-12) Adolescents (13-17) Young Adult (18-25) Adult (26-50) Seniors (50+) 4 Hosted by Autism Nova Scotia 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. 5945 Spring Garden Road Halifax, NS B3H 1Y4 Attn: Melissa Myers Respite Coordinator (For office use only) FM ID: ________ IN ID: ________ Rate of Pay: $10-$12 $12-$15 $15 $15+ Negotiable Per Diem Daily Rate Will work in the following areas: District 1: Waverly – Fall River – Musquodoboit Valley District 2: Preston – Chezzetcook – Eastern Shore District 3: Dartmouth South – Eastern Passage District 4: Cole Harbour – Westphal District 5: Dartmouth Centre District 6: Harbourview – Burnside – Dartmouth East District 7: Halifax South Downtown District 8: Halifax Peninsula North District 9: Halifax West Armdale District 10: Halifax – Bedford Basin West District 11: Spryfield – Sambro Loop – Prospect Road District 12: Timberlea – Beechville – Clayton Park West District 13: Hammonds Plains – St. Margarets District 14: Middle/Upper Sackville – Beaver Bank – Lucasville District 15: Lower Sackville District 16: Bedford – Wentworth Availability (other than summer months): (Check