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First Name
*
Last Name
*
Phone Number
*
Email Address
*
Preferred Method of Contact
Phone
Email
Text
Which of any of the following age groups are you interested in providing care for? (check all that apply)
Any age
Infants
Children
Teens
Adults
In which of the following Boone County locations are you available to provide care:
Anywhere
Ashland
Centralia
Columbia
Hallsville
Harrisburg
Sturgeon
Pierpont
Please select the semesters you are available:
Select All
Spring 2022
Summer 2022
Fall 2022
Spring 2023
Summer 2023
Fall 2023
Spring 2024
Summer 2024
Fall 2024
Which days and times are you available?
Select All
Sunday morning
Sunday afternoon
Sunday evening
Monday morning
Monday afternoon
Monday evening
Tuesday morning
Tuesday afternoon
Tuesday evening
Wednesday morning
Wednesday afternoon
Wednesday evening
Thursday morning
Thursday afternoon
Thursday evening
Friday morning
Friday afternoon
Friday evening
Saturday morning
Saturday afternoon
Saturday evening
How many hours per week are you available to work?
Other than English, which languages do you speak?
None
American Sign Language
Spanish
Other
Please list any other languages
Licensed/certified in
First Aid
CPR
Other
First Aid certification/license number and expiration
CPR certification/license number and expiration
Other certification/license number and expiration
How did you learn about this Caregiver Directory?
BCFR Self-Directed Services Coordinator
College/University Professor
Social Media or BCFR Family
Church/Other Community-led Organization
Work - Daycare, Secondary School, Adapted Classes, Tutoring, After School Program
Other
The Family Care Safety Registry (FCSR), administered by the Missouri Department of Health and Senior Services, provides employers with a method to obtain background screening information. Caregivers are not required to register with the FCSR in order to be listed in our Caregiver Database. However, families may require registration as a condition of employment. More information about the FCSR, along with instructions for registering online can be found here: http://health.mo.gov/safety/fcsr. Are you registered with the FCSR?
Yes
No
Please describe your skills and experience. If you have worked with individuals with developmental disabilities, please explain:
*
Upload a photo of yourself (optional)
Accepted file types: jpg, gif, png, Max. file size: 96 MB.
By selecting "I Agree," I agree to have my information, including my contact information, to become available to registered BCFR families via the online databases. I also agree to keep my information current and accurate.
*
I Agree
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