Employment Opportunities

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin or marital status.

Please provide the following information:
Personal Information:
Name:* Street Address:*
City:*
State:* Zip:*
Home Phone:* Cell Phone:
E-Mail: I am applying for a position as a:
Emergency Contact:
Name: Phone:
Address: Relationship:
Referred by:
Referred by:*
Specify ():*
Legal Record:
Have you ever been convicted of a felony? *
Yes: No:
Have you ever been convicted of a misdemeanor? *
Yes: No:
If Yes to either, please provide details.
Transportation:
Many caregiver positions require the caregiver to transport a client.
Do you have dependable transportation? Make and model of car:
Yes: No:
License plate #: Driver license #:
Auto insurance policy #: Insurance company:
Insurance agent name: Insurance agent phone:
Availability:
How many hours would you like to work per week?
Would you like a live-in situation? (2 or 4 days per week)
Yes: No:
Are you available to work nights? (graveyard shift)
Yes: No:
What times are you available to work?
Any times not available for work?
Allergies: (cats, dogs, dust, etc.)
Can you be called at the last minute in case of emergency?
Yes: No:
Comments:
Education:
High School:
Name: City/State:
Start Date: End Date:
College:
Name: City/State:
Start Date: End Date:
Other:
Name: City/State:
Start Date: End Date:
Degrees/Certificates:
Special Skills/Courses:
Experience:
Please list any training or experience you have working with the elderly.
What would you like most about working with the elderly?
What would you like least about working with the elderly?
Skills:
Please indicate whether you have assisted with or performed the following tasks for seniors.
Companionship:
Yes: No:
Bathing/Dressing:
Yes: No:
Bathing/Full Assist:
Yes: No:
Grooming:
Yes: No:
Incontinence:
Yes: No:
Incontinent/Full Assist:
Yes: No:
Transfer Assist:
Yes: No:
Vacuuming:
Yes: No:
Dusting:
Yes: No:
Clean bathrooms:
Yes: No:
Clean kitchen:
Yes: No:
Bed Linen Changes:
Yes: No:
Laundry:
Yes: No:
Grocery Shopping:
Yes: No:
Cooking:
Yes: No:
Driving:
Yes: No:
Alzheimer's Experience:
Yes: No:
Dementia Experience:
Yes: No:
Medication Reminders:
Yes: No:
Lifting:
No Lifting: 25 lbs or less:  
25-50 lbs:  50-75 lbs:
75+ lbs: 
Employment History:
Please enter the following information about your three most recent jobs. Please put the most recent first
Company: Job Title:
Reason Left:
Duties:
Supervisor: Supervisor phone:
Start Date: End Date:
May we contact your current employer?
Yes: No:
Company: Job Title:
Reason Left:
Duties:
Supervisor: Supervisor phone:
Start Date: End Date:
Company: Job Title:
Reason Left:
Duties:
Supervisor: Supervisor phone:
Start Date: End Date:
Personal References:
Please enter the following information for personal references that you would like us to contact.
Name:* Address:
Phone:* Relationship/Years Known:
Name:* Address:
Phone:* Relationship/Years Known:
Name:* Address:
Phone:* Relationship/Years Known:
More...
Certification of Release:
I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
Agree: Disagree: