Become a Provider

Respite4Kids partners with the Ohio Respite Alliance for provider enrollment. This form will guide you through joining the Ohio Respite Alliance as a Respite4Kids provider before you can begin providing services through our program.

First Name

Middle Name

Last Name

Phone Number

Allow Communication via Texting

YesNo

Address

City

County

State

Zip Code

Date of Birth

SSN (last 4 digits)

Enter only the last 4 digits of your Social Security Number.

Are you a citizen or green holder of the United States?

YesNo

Have you ever been convicted of a felony

YesNo

If yes, please click here for a list of disqualifiers

Create a Login

Password

Password should be at least 10 characters, with at least 1 uppercase, 1 lowercase, and 1 special character.

CONFIRMATION: I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature Clear

Date