Join Our Care Team Today We are always looking for responsible and dependable caregivers. If you have a passion for helping the patients in need, please fill out an online application today. EMPLOYMENT APPLICATION Caregiver applicants are required to undergo a criminal background check*. ALL INFORMATION WILL REMAIN CONFIDENTIAL. We are an equal opportunity employer/ PERSONAL AND GENERAL INFORMATION *Today's Date *First Name M.I *Last Name *Address Apt./Unit# *City *State *Zip *Home Phone Number *Cell Phone Number *Email Address Are you 18 years of age or older? Yes No List other name you have been known by: Placement you are seeking Full Time Part Time No Preference Has your license ever been limited, suspended, or revoked? Yes No If yes Please Explain Are you Eligible for Work in the USA? Yes No Have you ever applied here before? Yes No if Yes What Year *Emergency Contact 1. Name Realtionship: Phone: 2. Name Realtionship: Phone: *Transportation Some clients require trasportation. Do you have a Driver's License? Yes No Proof of auto insuranse? Yes No Do you have a personal Vehicle to drive to work? Yes No How Far are you willing to drive (miles) How did you hear about this Job? List all the languages you speak? Are you applying for this job to work for a family Member? Yes No Specialized Experince, Volunteer Work Training / Skills Indicate months/years of experience for all that apply - for example: 6 mo. Mobility Aids; 2 yrs. Stroke Time Frame mo.yrs. Alzheimer's/Dementia mo.yrs. Bathing Males/Females mo.yrs. Bedpan Toileting mo.yrs. Blind/Visually Impaired mo.yrs. Blood Sugar Testing mo.yrs. Skin Care mo.yrs. Care of Pressure Area mo.yrs. Parkinson's Disease mo.yrs. Positioning mo.yrs. Temperamental Client Time Frame mo.yrs. Colostomy Bag mo.yrs. Depression/Mental Instability mo.yrs. Diabetic mo.yrs. Epileptic mo.yrs. External Foley Care mo.yrs. Feeding Tubes mo.yrs. Foley Catheter mo.yrs. Preparing Special Diets mo.yrs. Stroke mo.yrs. Vital Signs/Blood Pressure Time Frame mo.yrs. Foot Edema mo.yrs. Heart Disease mo.yrs. Medication Monitoring mo.yrs. Mentally Handicapped mo.yrs. Mobility Aids mo.yrs. Non-Sterile Dressing mo.yrs. Oxygen mo.yrs. Weight mo.yrs. Hoyer Lift mo.yrs. Other Check Mark to all skills that applies to you Dustin Furniture Mopping/Vacuuming Floor Washing Dishes Ironing Laundry Cooking Bed making/Changing Linens Special Diets Shave Hair Washing Shower Bath Assist Incontinent Care Catheter Care Bed Sores Care Galt Belt Wheelchair Safety Hoyer Lift Accue Check B.p Pulse CPR Interests / Hobbies Please list any skills, hobbies, or other activities that would contribute to your proficiency as a caregiver. Many 12- and 24-hour jobs include considerable amounts of unstructured time, and leisure time participation with the client is important. Please indicate activities you enjoy and/or are able to teach to someone else. Medical Due to the fact we match client needs with caregiver abilities, please list any physical or mental limitations and/or impairments that would have a direct effect on providing care to clients. For example: cannot lift more than 10 pounds due to back/ On medication and cannot drive while taking it. *Education High school College Other *Employment History Carefully fill in the information below. Volunteer experience may be substituted if there is no employment history. In order to process your application, you must provide complete names and addresses of your employers. Without this information your application cannot be processed Present or Most Recent Employer Company Name Company Phone # Supervisor's Name Supervisor's Phone # Address: City State Zip Code: Employed from: to Reason for Leaving: Company Name Company Phone # Supervisor's Name Supervisor's Phone # Address: City State Zip Code: Employed from: to Job Duties: Reason for Leaving: Company Name Company Phone # Supervisor's Name Supervisor's Phone # Address: City State Zip Code: Employed from: to Job Duties: Reason for Leaving: PERSONAL REFERENCES A minimum of three (3) references, including complete mail addresses, is required.Do NOT use family members or past supervisors. 1 Name: Full address: Relationship Telephone 2 Name: Full address: Relationship Telephone 3 Name: Full address: Relationship Telephone *Availability Please put a check mark in the box of your availability Days AM PM ON CALLS COMPANION HOLIDAYS Monday ### ### ### ### ### Tuesday ### ### ### ### ### Wednesday ### ### ### ### ### Thursday ### ### ### ### ### Friday ### ### ### ### ### Saturday ### ### ### ### ### Sunday ### ### ### ### ### Caregiving requires a high degree of dependability. Describe why you feel you are dependable. Give Examples. Tell Us about you If your record shows that you have been convicted (in any state) of a crime that is equivalent to a crime on the list above or a crime that has been renamed, you may be disqualified or determinated If a court, state department, disciplinary board, or dependency action has found that you have abuse, neglected, exploited, or sexually abused any minor or vulnerable adult, you are automatically disqualified from employment and/or placement through this organization. If your record shows that you have been convicted of other crimes related to care of vulnerable adults or children, you may be disqualified from employment and/or placement through this organization. Have you ever been arrested or convicted of any of the crimes listed above? Yes No if Yes - Please describe: I certify that information I have provided in this employment application is accurate and been completed to the best of my knowledge and ability. I understand that any falsification, misrepresentation or omission in my interviews or any other employment record, may be sufficient reason not to hire me or may be reason for dismissal.
