Assistant Enrollment Application
We want to make participation in the DAC-PAS program as easy and effortless as possible. That's why our website contains just about everything you need to effectively be a part of the DAC-PAS team. From forms to manuals, Medicaid information to web links, we hope you find what you're looking for. And, if you don't, please always feel free to contact us and we'll be more than happy to help in any way we can.

Print Versions             General Application: -PDF Format -MS Word       If you would prefer to print your application, complete it on paper, and mail or deliver it to us, please choose one of the applications and formats to the left. Otherwise, please scroll down to begin the onilne, electronic application.               Coeur d'Alene Application: -PDF Format -MS Word

PERSONAL INFO Experience References Competencies Submission     FIRST NAME: LAST NAME: ADDRESS 1: ADDRESS 2: -- CITY: STATE: ZIP: -- E-MAIL ADDRESS: --   PHONE: - - ALTERNATE PHONE: - - HOW MAY WE CONTACT YOU? Telephone E-Mail Postal Mail HOW DID YOU HEAR ABOUT DAC-PAS? (Select) Word of Mouth Internet Search Engine Newspaper Other -- ARE YOU 18 YEARS OF AGE OR OLDER? Yes No PLEASE TELL US ABOUT YOUR HOBBIES AND INTERESTS:               Personal     WORK EXPERIENCE References Competences Submission     -1. COMPANY / INDIVIDUAL: PHONE: - -     POSITION: DURAION:     DESCRIPTION: -2. COMPANY / INDIVIDUAL: PHONE: - -     POSITION: DURAION:     DESCRIPTION: -3. COMPANY / INDIVIDUAL: PHONE: - -     POSITION: DURAION:     DESCRIPTION:               Personal Experience     REFERENCES Competences Submission     -1. FIRST NAME: LAST NAME:     RELATIONSHIP: PHONE:   - - -2. FIRST NAME: LAST NAME:     RELATIONSHIP: PHONE:   - - -3. FIRST NAME: LAST NAME:     RELATIONSHIP: PHONE:   - -               Personal Experience References COMPETENCIES Submission     -1. ARE YOU A CNA?   Yes No -2. WOULD YOU BE ABLE TO ASSIST IN TRANSFERRING AN INDIVIDUAL WHO USES A WHEELCHAIR?   Yes No -3. PLEASE LIST ANY SKILLS YOU HAVE THAT WOULD BE BENEFICIAL TO THIS POSITION:   -4. PLEASE LIST ANY LIMITATIONS OR CONDITIONS OF EMPLOYMENT:   (i.e. hours of availabiliy, gender, etc.) -5. PLEASE INDICATE YOUR LEVEL OF COMFORT WITH THE FOLLOWING:   NO PERSONAL CARE   (housekeeping, laundry, shopping, transportation. Cooking) SOME PERSONAL CARE   (bathing, toileting (assist), dressing, mobility) COMPLETE CARE   (toileting, bowel program, catheter, feeding, etc.)                 Personal Experience References COMPETENCIES Submission     -1. HAVE YOU COMPLETED A CRIMINAL BACKGROUND CHECK IN THE LAST YEAR?   Yes No -2. DO YOU HAVE RELIABLE TRANSPORTATION?   Yes No -3. PLEASE INDICATE THE AREAS IN IDAHO IN WHICH YOU WOULD LIKE TO WORK:   MOSCOW-BASED LOCATIONS: Moscow Troy Potlatch Julietta Lewiston Orofino Other:   COEUR D'ALENE-BASED LOCATIONS: Couer d'Alene   St. Maries   Kellog   Hayden   Sandpoint   Bonners Ferry   Other:             -4. WHEN ARE YOU AVAILABLE TO WORK?   Full-Time Part-Time Weekends Emergency               Personal Experience References Competencies   SUBMISSION