Another Day Care Giver Information Sheet

Another Day is a fiscal agent for families able to receive services for developmentally challenged individuals using Home Community Based Services in Kansas and Missouri. Another Day helps the parent or guardian locate care givers to work for their developmentally challenged family member.

It is understood that the families you will work for will use Another Day as the fiscal agent.
Website: www.anotherday.info
Address: 11802 West 77th Street, Lenexa, Kansas 66214
Fax: 913-599-5660
Name (First & Last): Date:
Address: City: State: Zip:
Phone: Cell: Alt:
What are the maximum hours per week that you are available to work?
What is the maximum distance you are willing to travel?
What college did you attend?
How did you hear about us?
Missouri Kansas
Cass Clay Jackson Platte Ray Johnson Wyandotte Johnson Miami
Other Other
Days and hours that you would be available:
  MON TUE WED THU FRI SAT SUN
Day
Evening
Night
Please enter the time(s) in the appropriate boxes above. If you are not available to work on a day, do not fill in the box for that day. An example would be if you can work on Mondays during the day, go to the "MON" column, the "Day" row and enter the hours "1pm - 3pm"
Job Experience:
Certifications:
Word Verification:
Job duties may include:  personal care, social activities, academics, recreational activities, and lifting etc.
 
Please be aware that you are only submitting informaion in order for Another Day to
contact you. This information does not imply or guarantee work. You must have
contact with the office and undergo a background check before employment
can be offered. By checking this box you agree to having had read this disclosure.
 
I affirm that all of the information provided above is accurate to the best of my
knowledge and I understand that falsification of any of this information
is cause for immediate termination and possible litigation.
I have also read and agree to the terms of disclosure of this information.
Yes     No