Wisconsin Quality Home Care Commission // How to Provide Care

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Individuals interested in providing care can contact the WQHCC staff by phone at (608) 630-8402 or by completing the form below. After the initial screen is complete, staff will follow up to get more information and complete the necessary background checks.

	Note: Fields noted with the red asterisk (*) are required.
Your Name:*
Street Address:*
City / State / Zip:*
Phone:*
E-mail address:*
Referred by:
Type(s) of Care:*	Respite - Family Home Respite - Provider Home Personal Care Worker Inclusion Facilitator - Center/School Based Inclusion Facilitator - Community Based Teen Mentor Event Volunteer Therapy Provider
Availability:*	Weekdays Evenings Overnights Weekends
Commitment:*	1 year Summer only One time event Unsure
Have access to car:*	yes no
Please tell us about your training and experience:*
Children or Adults with Disabilities:
Other Care Related Experience:
Other Employment:
Education/Degree:
Do you have any plans which may change your ability to proceed with this application process?
Other Comments: