Take the First Step

— ic relief application

Complete the form below to apply as an IC Relief. Please provide as much detailed information as possible.

IC Relief Application
Applicant Information:
Name
Address
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Please enter your full date of birth.
Educational Information:
High School Graduate:
Do you speak any other languages fluently?
Other specialized training(s): Check all that apply.
Vehicle Information:
Do you have a vehicle?
Do you have a valid driver's license?

The applicant must provide proof of current auto liability insurance with a minimum personal injury coverage of $300,000.

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.
Please upload a current copy of your auto insurance card or policy. This is required for any driving-related support.
Personal References:

List at least 3 personal references (not family). Include people who can speak to your character, such as a former employer, coworker, or community member.

Please ensure your references are aware they may be contacted.
Pre-Interview Questionnaire:
Have you worked for Progressive Community Network before?
Have you ever been convicted of a felony, child abuse, or a sexual offense?
Have you ever been arrested for anything other than minor traffic violations?
Do you have experience supporting individuals with developmental disabilities?
Do you have any regular commitments that would require you to be away from home during the day or evening?
Could you care for an adult who cannot be left unattended?
I could best support a person with the following care needs (choose one, or all that apply):
Of the behaviors listed below, select all that you would be willing to work with:
Is there a particular individual for whom you are interested in providing services?
Clear Signature
I certify that I have truthfully answered the above questions to the best of my ability. I understand that providing false or misleading information may result in the cancellation of my Relief/Back-up Coverage Contract. Failure to complete any section of this application may be cause for you to not be considered further.
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Our mission, guided by the motto of “Care and Compassion,” is to deliver outstanding care to individuals of all abilities, and to foster complete inclusion across all facets of life.

Business Hours:

Mon: 9:30AM – 4:30PM
Tues: 8:30AM – 4:30PM
Wed: 8:30AM – 4:30PM
Thurs: 8:30AM – 4:30PM
Fri: 8:30AM – 1:30PM

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P: (515 ) 270-5353
F: (515) 993-2036
EMAIL US

Address:
8410 Hickman Road
Suite 102
Clive, IA 50325

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