Family Referral of Applicant Form

Are you a CISS authorized family who wants to refer someone you already know to be hired as your Support Staff? If yes, complete the form below for each person you are referring. The person(s) you refer must be eligible to work in the U.S., pass a livescan background check, and be at least 16 years old.

Please obtain the full name, phone number and email address of the person you are referring before completing this form.

If you have any questions completing the form, please contact our office at (805) 384-0983. Thank you!

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Name of Parent/Guardian Completing Form *

First

Last

Full Name of Person Receiving Support Services *

First

Last

(The child or adult who is authorized by the regional center or by the County of Ventura to receive care from CISS)

ServicesRespite CarePersonal Assistance (PA)Both Respite and PA

Phone Number of Family *

Must match phone number in our database or our office will need to reach out to confirm.

Family's Email Address *

Must match email address in our database or our office will need to reach out to confirm.

Name of Person Family is Referring for Employment *

First

Last

I hereby designate the above individual to provide support services for my family. I believe this person to be of good moral character and have known them for the following years or months: *

(How long have you known the person you are referring? Make sure to include “years” or “months”)

Relationship of Applicant to Family *

(How you know this person.
Example: friend, neighbor, how the applicant is related to the person authorized to receive care)

Phone Number of Support Staff Applicant *

Applicant's Email Address (if known)

If you do not know their email address, please ask them. It helps us expedite the application process.

LIABILITY – The determination in designating this Support Staff is my sole responsibility, based on my personal knowledge of, and relationship with, this person and I waive any and all claims and/or actions against Channel Islands Social Services (CISS) for my decision. I understand that if CISS finds this Support Staff to not be eligible for employment in the United States, or according to agency policies, that CISS may choose to not employ this person and that such findings are highly confidential and may not be shared with me. *

• I understand

JOINT EMPLOYER / ONSITE SUPERVISOR – As the parent or primary caregiver, I understand that I am considered the joint employer and onsite supervisor in my home of this person. CISS is the employer of record responsible for all final hiring decisions, background screening, payroll, worker’s compensation claims, and final termination decisions. I understand that it is my responsibility to schedule my support service hours up to my authorized amounts and keep careful track of all hours. I agree to pay the Support Staff directly for all hours they work and miles they drive that exceed my authorization as that is considered private pay work. Should I have any concerns in the future regarding this employee, I will contact CISS immediately. *

• I understand

JOB DUTIES. I have received a copy of the Respite Caregiver and/or Personal Assistant job descriptions, and I attest that this person meets or exceeds the stated minimum requirements for the position. I agree to only ask the employee to supervise my authorized the authorized individual. For respite care, I further agree to privately compensate them for additional siblings that they agree to supervise at the same time as the authorized individual. At no time will I request that this employee perform duties outside of the job description. I understand that all CISS employees must work regularly, at least an average of 8 hours/month, to remain actively employed by CISS. *

• I understand

Please review the Respite Caregiver job description then return to complete the rest of this form.
https://www.islandsocialservices.org/respite-caregiver-jd/

TRAVEL. I understand that all care must be provided in my home or within five miles. All CISS employees who transport individuals in their care must have a Travel Authorization form on file pre-approved by CISS, be at least 21 years old, and be on the CISS approved driver’s list with proof of insurance requirements, and a clean driving record. *

• I understand

AGREEMENT – Unless revoked, this waiver will remain in effect during my family’s service authorization for services provided by Channel Islands Social Services. *

• I agree to these terms

Address of Authorized Family

Address Line 1

Address Line 2

City

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