Iowa Care Givers Association
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Caring for Caregivers

U-ROC Registration

Click here to download a PDF version of the Iowa CareGivers Resource and Outreach Center brochure that you may print out and mail in, or you may also register by filling out the form here.

Mail to:
Iowa CareGivers Association
Direct Care Worker Resource & Outreach Center (ROC)
1211 Vine Street, Suite 1120
West Des Moines, IA 50265

Sign up with the Iowa CareGivers
Resource and Outreach Center

Notice: A separate registration is required for each person attending.

  Male:    Female:
  Mr.    Mrs.    Ms.
*Full Name:
*Job Title:
*Employer:
*Home Mailing Address:
*City:
*State:
*Zip:
*County you live in:
*Phone (home):
Phone (work):
Phone (other):
Email:

 

Please check the box that best describes your position or title:
Certified Nursing Assistant (CNA) Home Care Aide (HCA)
Patient Care Technician (PCT) Hospice Aide
CNA plus other certification, such as medication aide, rehabilitation aide, etc. Home Health Aide (HHA)
Consumer Directed Attendant Care
(CDAC) worker or Personal Care Assistant		 Companion, non-medical
assistant
Universal Worker Other

If you chose "Other" above, please note your position or title as a direct care worker:

On your MAIN direct care job, where do you work most
of your working hours?

Nursing home People's homes
(not including hospice)
Hospice – inpatient or in-home Group Home
Assisted living, independent living Home Health Aide (HHA)
Adult Day Center Hospital
Residential Care Facility (RCF) Other
If you chose "Other" above, please note your position or title as a direct care worker:

Which ONE group do you mainly provide services for on
your MAIN direct care job?

Older adults Persons with disabilities of all ages
Other  
If you chose "Other" above, please note your position or title as a direct care worker: