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IC Relief Application

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

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IC Relief Application
Applicant Information:
Name
Address
Please enter your full date of birth.
Educational Information:
High School Graduate:
GED or High School Equivalency:
Do you speak any other languages fluently?
Other specialized training(s):
Check all that apply.
If you have additional specialized training not listed above, please enter it here (e.g., CPR, Crisis Intervention, Autism Certification, etc.).
Vehicle Information:
Do you have a vehicle?

Vehicle Type:

Please list make, model, and year of your vehicle.
Do you have a valid driver's license?

Please provide the state of issue, driver’s license number, and expiration date:

Example: Iowa, D12345678, 01/01/2027
Click or drag files to this area to upload. You can upload up to 2 files.
This is required to verify your identity and eligibility to provide transportation if needed. Accepted formats: JPG, PNG, or PDF

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

Click or drag files to this area 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:

Please list at least three personal references. Include name, phone number, email address and relationship to you.

Name
Pre-Interview Questionnaire:
Have you been employed by Progressive Community Network previously?
Have you ever been convicted of a felony, child abuse, or a sexual offense?
Have you ever been arrested for violations of the law other than minor traffic violations?
Do you have any experience or exposure to the Developmental Disability community?
Do you have any obligations that would require you to be away regularly 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?
If yes, please name:
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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