Skip to form

Inland Regional Center

info@inlandrc.org

1365 S. Waterman Ave., San Bernardino, CA, 92408, US

Form Section 1

DAY SERVICES ORIENTATION APPLICATION

Applicant

Applicant Name
Address
Please attach a copy of your identification, as well as your professional resume for review
Form Section 2

Experience Providing Services or Direct Supervision to Individuals with Developmental Disabilities

Time Employed
Company Address
Time Employed
Company Address
Form Section 3

Education (Most recent first)

School Address
Dates Attended
School Address
Dates Attended
School Address
Dates Attended
Form Section 4

Professional References

Please attach 3 reference letters, must include contact information and be signed
What type of Day Service are you Interested in Providing? (Check all that apply)
Have you ever been vendored by IRC or another regional center?
Please attach a copy of your most recent Quality Assurance Evaluation

Applicants applying for Day Services Orientation who are currently vendored providers for IRC or any regional center, must have services in good standing.