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#1 - Your Basic Info

Birthday
Month
Day
Year
Your Credentials
Multi-line address
Desired Position
Desired Status
Are you a 1099 DOH Approved Provider?
Yes
No
Preferred Coverage Areas

#2 - Submit Your Docs

Use this HR/Applicant Checklist to keep track of what you have submitted.

  • Each time you visit this page to submit more documents, please enter your name and always click "Submit" at the bottom of this form.

Select if you are a W2 Employee or 1099 Contractor
W2 Employee
1099 Contractor

  • IMPORTANT: Based on your response, this form will require additional documentation specific to either W-2 employees or 1099 contractors.

For ALL Staff, please submit:

  • If needed - click here for blank SCR Form

  • If needed - click here for blank medical exam form

  • The "Degree" option is available for Service Coordination positions only. All other positions require a license or certification.

  • If needed - click here for blank I9 form

  • Please include 3 references

  • if you do not have NPI#, please click here to register for one

  • 10 hrs needed per year. Click here for specific requirements

  • Sign up & take the 5 modules on Family Centered Practice here

  • Click here for training link

  • $1 million per claim/$3 million aggregate policy needed.

  • For a company suggestion, click here.

  • Only SCs do NOT need this

  • click here for a blank

#3 - Documents to Sign

Recommended Vaccinations 

Acceptance / Declination Form

I have been informed regarding the availability and advisability of receiving the following vaccinations: Hepatitis B (3-injection series}, Pertussis, Varicella, and Influenza 


Please check your choice to receive or decline the following: 

Hepatitis B (3-injection series):
I do not wish to receive the Pertussis vaccination at this time. Should I change my mind, I will furnish proof to Bright Future for the Children of my vaccination.
I do wish to receive the Pertussis vaccination. I will furnish proof to you of any vaccinations.
Pertussis:
I do not wish to receive the Pertussis vaccination at this time. Should I change my mind, I will furnish proof to Bright Future for the Children of my vaccination.
I do wish to receive the Pertussis vaccination. I will furnish proof to you of any vaccinations.
Varicella:
I do not wish to receive the Varicella vaccination at this time. Should I change my mind, I will furnish proof to Bright Future for the Children of my vaccination.
I do wish to receive the Varicella vaccination. I will furnish proof to you of any vaccinations.
Influenza:
I do not wish to receive the Influenza vaccination at this time. Should I change my mind, I will furnish proof to Bright Future for the Children of my vaccination.
I do wish to receive the Influenza vaccination. I will furnish proof to you of any vaccinations.
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Documents to Sign

Bright Future for the Children

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