* Which of the following best describes your current caregiving situation?

* Which Epic Nursing Services program are you interested in?

* How much experience do you have providing personal care or assistance to an adult?

* Which of the following caregiving activities do you have experience assisting with? Select all that apply.

* Are you currently providing care to an adult who may be interested in receiving services through Epic Nursing Services?

* Please provide your employment history for the past five years, including employer name, job title, dates of employment, primary responsibilities, and reason for leaving. Include relevant caregiving experience, whether paid or unpaid. If you have no previous employment history, enter "No previous employment."

* Please provide two professional or caregiving references who can speak to your experience, reliability, and ability to provide care. For each reference, include their full name, relationship to you, organization (if applicable), telephone number, and email address (if available). Please do not list anyone receiving care from you. If you cannot provide two references, explain why.

* Please provide your highest level of education and list any relevant caregiving or healthcare training, certifications, or licenses you have completed. Examples include CNA, HHA, PCA, CPR, First Aid, dementia care, medication assistance, or other caregiver training. Include the issuing organization and expiration date, if applicable. If you have no certifications or formal training, enter "None."

* Which caregiving schedules or arrangements are you interested in or currently available to provide? Select all that apply.

* Which languages can you comfortably speak and understand when providing caregiving services? Select all that apply.

* If you are currently caring for someone or have identified a prospective member, what is your relationship to that individual?

* If you currently care for an adult or have identified someone who may be interested in Epic Nursing Services, please provide the prospective member's full name, city and state of residence, your relationship to them, and whether you currently live together. If the individual has authorized Epic to contact them, you may also provide their preferred telephone number. Do not include Social Security numbers, insurance identification numbers, diagnoses, or other medical information. If you have not identified a prospective member, enter "Not Applicable."

* Have you previously worked or participated as a caregiver with an Adult Foster Care (AFC), Group Adult Foster Care (GAFC), Adult Family Living (AFL), home care, or similar healthcare service provider? If yes, provide the agency name, state, program type, approximate dates of participation, and whether you are currently providing services through that agency. If you have never participated in these programs, enter "No previous program participation."

* Are you willing to complete all applicable caregiver screening and compliance requirements for the program in which you are applying?

Massachusetts (AFC/GAFC): Criminal Offender Record Information (CORI), Sex Offender Registry Information (SORI), Office of Inspector General (OIG) exclusion screening, and any other applicable background or registry checks.

Connecticut (AFL): Connecticut criminal history background screening, sex offender registry screening, applicable abuse and neglect registry screening, OIG exclusion screening, and any additional checks required by Connecticut DSS or the applicable program.

* If selected and all applicable eligibility, screening, training, and program authorization requirements have been completed, when would you be available to begin providing caregiving services through Epic Nursing Services?

* Applicant Certification and Acknowledgment

I certify that the information provided in my application to Epic Nursing Services LLC, including my personal information, employment history, qualifications, references, caregiving experience, and any prospective member referral information, is true, accurate, and complete to the best of my knowledge.

I understand that Epic Nursing Services may verify information relevant to my qualifications and eligibility, subject to applicable laws and required authorizations.

I understand that material misrepresentations, falsified documents, or intentional omissions may result in disqualification from consideration or termination of an applicable employment or caregiver arrangement, subject to applicable law.

I agree to notify Epic Nursing Services if any material information provided in my application changes during the recruitment or onboarding process.

Do you certify and acknowledge the statements above?

* Applicant Electronic Signature

By signing below, I confirm that I have reviewed my application and certify that the information I have provided is accurate and complete to the best of my knowledge.

I understand that my electronic signature serves as my acknowledgment of the Applicant Certification and Acknowledgment statements above.

I understand that submitting this application does not guarantee employment, caregiver approval, program enrollment, or authorization to begin providing services.

Please provide your electronic signature below.