Application to provide SSP services with Vancro

Which state SSP Program are you applying to?

Missouri
Vermont
New Mexico
Nebraska

First Name

Middle Initial

Last Name

Address

City

State

Zip

Phone

Please note if it is voice, text, or VP

If you have an additional phone number, please list it here.

Note if it is a voice, text, or VP.

Email

Preferred Method of Communication

Select all that apply

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Email

Which best describes your level of hearing?

Deaf
Hard of Hearing
Late-Deafened
Hearing
Other

My sign language skills are best described as:

Select all that apply

Do you have SSP experience?

Yes
No

Are you willing to undergo a background check?

This is a requirement to become an SSP.

Yes
No

Which trainings have you completed?

Do you give your permission to include your contact info in an SSP directory to be sent directly to consumers of the SSP program?

Yes
No

Do you have a valid Driver's license?

Yes
No

Do you consent to Vancro requesting your driving records from the DMV?

Yes
No

Do you agree to complete the required SSP training and annual file review process?

This includes completing annual training requirements.

Yes
No

Applicant Signature and Information Release

The above facts are true and complete to the best of my knowledge. I authorize Vancro to send my personal profile to the appropriate state agencies for the purpose of evaluating the SSP Program. Type applicant signature

Date

Which consumers have you worked with in the past?

List names of consumers.

In general, when are you available to work as an SSP?

Ex. I work full time and am available evenings and weekends.

{name}

How did you hear about this position?

Ex. word of mouth, referral, Facebook, etc.

The following questions are entirely optional and declining to answer will not impact your ability to provide services.

My pronouns are:

Ex. they/them, he/his, she/hers, etc.

Are you of Hispanic, Latino, or of Spanish origin?

Yes
No

How would you describe yourself?

What is your Marital Status?

What is the highest degree or level of school you have completed?

If you are currently enrolled in school, please indicate the highest degree you have received.

Less than a high school diploma
High school degree or equivalent (GED)
Some college, no degree
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate

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