Respite/Habilitation Schedule Request Form

Please fill out this form regarding your schedule availability.

Reason For Schedule Request*

My Schedule Has Changed

My Client's Schedule Has Changed

I am a New Employee

EE Support Services requested an update.

First name*

Last name*

Phone number*

Your phone number .

Email*

Your email address

Street address

City*

City of Residence

Main Cross Streets *

Please list the major intersection near your residential address.

Zip Code *

Please list one or multiple zip codes that fit your geographic preference for providing support services.

Please select the age range for clients you are comfortable working with.*

Please note: This could limit the number of families in need of support that are available to you.

0-5 years old

6-10 years old

11-17 years old

18 years or older

No Preference

Please select the days you are available to provide support services*

Select all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How many hours per week are you wanting to work per week total?*

Please list the specific dates and times you are available to provide support services*

Example: "8:00am -12:00pm 12/21- 12/23 & 8:00am - 6:00pm 12/28- 12/31"

Schedule Start Date*

Please enter a preferred start date.

Additional Comments

Please use this space for comments or to indicate if there are specific dates that you will be unavailable.

"Don't wait. The time will never be just right. Start where you stand, and work whatever tools you may have at your command and better tools will be found as you go along." Napoleon Hill