WI Respite Care Registry

Respite Provider Registration

First Name *

Last Name *

Phone *

Email *

Are You an Agency? *

Yes

Agency Name

Have You Completed Respite Care Provider Training (RCPT)? *

Yes

Experience/History *

Education/Certifications/Licenses

Other Trainings Completed

Counties You Serve *

Select all that apply.

Ages You Will Work With: *

Hours Available to Work

Type of Respite You Provide *

Select all that apply.

Profile Picture *

Resume *

Bio

Background Check

Have you had a Background Check performed within the past three (3) years? *

Yes

By registering as an individual provider or an agency, I hereby certify under penalty of perjury the following:

I have not been convicted of a felony in any jurisdiction and have no pending felony charges in any jurisdiction.
I am not a registered sex offender and have not been charged with any sex-related crime.
I have not been adjudicated as incompetent or with a mental defect by a court of jurisdiction.
I am not the subject of any abuse or domestic violence injunction or restraining order.
I, as an individual and/or the agency (if applicable), am not listed on the Wisconsin DHS Caregiver Misconduct Registry per Wis. Stat. Sec. 146.40, Wis. Admin. Ch. DHS 13, or any other similar registry in a different jurisdiction
I, as an individual and/or the agency (if applicable), have not had any license, certificate, permit or registration required under Wis. Stat. Ch. 440 to 480 or by the laws of another state suspended or revoked, and I (and/or the agency) am not currently being investigated for any of the above.
If applicable, the agency is in good standing with the U.S. Department of Health and Human Services, Wisconsin Department of Financial Institutions, Wisconsin Department of Human Services, Wisconsin Division of Quality Assurance, Medicaid, or any other regulatory bodies.
I acknowledge RCAW absolutely prohibits any individual providers or agencies who are subject to any of the above-listed circumstances from being listed on the registry at any time. RCAW does not provide any inquiries or background checks into providers. I agree to notify RCAW immediately if I, as an individual and/or the agency (if applicable), am ever subject to any of the above-listed circumstances now or in the future.

By checking the box, I agree to the above terms and conditions. Additionally, I have read and agree to the full Terms and Conditions linked here.

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