Information About You

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* 1. First Name

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* 2. Last Name

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* 3. City

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* 4. Cell Phone (Enter number without dashes or parentheses)

By providing my phone number, I understand that District 1199 NE may use automated calling technologies and/or text message me on my cellular phone on a periodic basis.  District 1199 NE will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text a reply “STOP” to stop receiving texts from District 1199 NE.

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* 5. Email Address

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* 6. Preferred Language

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* 7. Which race describes you best?

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* 8. As a home care provider, I provide services for the following number of Consumers (through Allied or Sunset Shores)

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* 9. As a home care provider through Allied or Sunset Shores, I provide services to a Consumer who is: (check all that apply)

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* 10. For all your consumers combined through Allied or Sunset Shores, how many hours do you work on average?

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* 11. What is your age range?

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* 12. If you have another job besides Allied or Sunset Shores, where do you work?

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