|
|
Personal Information
|
|
|
* Denotes required fields
|
|
* First Name:
|
|
|
* Last Name:
|
|
|
Present Address:
|
|
|
City:
|
|
|
State:
|
|
|
Zip Code:
|
|
|
* Phone:
|
|
|
* E-mail Address:
|
|
|
Do you smoke?
|
|
What type of position are
you applying for?
|
|
|
Are you over 18?
|
|
|
U.S. Citizen?
|
|
|
|
If "no," can you furnish legal proof of work permit?
|
|
|
|
Referral Information
|
|
How were you referred to us?
|
|
|
Other:
|
|
Legal Record
|
Have you ever been convicted
of a felony?
|
|
Have you ever been convicted
of a misdemeanor?
|
|
|
Details:
|
|
Transportation
|
|
Do you drive?
|
|
|
Valid Driver's License #:
|
|
|
State:
|
|
|
Do you have auto insurance?
|
|
|
Provider:
|
|
Former Employers
|
|
Are you currently employed?
|
|
|
May we call current employer?
|
|
|
Most Recent Employer
|
|
Name of Employer:
|
|
|
Employment Dates From:
|
To:
|
|
Phone:
|
|
|
Address:
|
|
|
Job Title:
|
|
|
Supervisor:
|
|
|
Salary:
|
|
|
Duties:
|
|
|
Reason for Leaving:
|
|
|
Employer 2
|
|
Name of Employer:
|
|
|
Employment Dates From:
|
To:
|
|
Phone:
|
|
|
Address:
|
|
|
Job Title:
|
|
|
Supervisor:
|
|
|
Salary:
|
|
|
Duties:
|
|
|
Reason for Leaving:
|
|
|
Employer 3
|
|
Name of Employer:
|
|
|
Employment Dates From:
|
To:
|
|
Phone:
|
|
|
Address:
|
|
|
Job Title:
|
|
|
Supervisor:
|
|
|
Salary:
|
|
|
Duties:
|
|
|
Reason for Leaving:
|
|
|
Employer 4
|
|
Name of Employer:
|
|
|
Employment Dates From:
|
To:
|
|
Phone:
|
|
|
Address:
|
|
|
Job Title:
|
|
|
Supervisor:
|
|
|
Salary:
|
|
|
Duties:
|
|
|
Reason for Leaving:
|
|
References
|
|
List three references, not related to you, who may be contacted.
|
|
#1 Name:
|
|
|
Phone:
|
|
|
Address:
|
|
|
|
|
#2 Name:
|
|
|
Phone:
|
|
|
Address:
|
|
|
|
|
#3 Name:
|
|
|
Phone:
|
|
|
Address:
|
|
Availability
|
|
How many hours per week?
|
|
Would you like a live-in situation
(3 or 4 days per week)?
|
|
Would you like graveyard
hourly shifts?
|
|
What times are you
available to work?
|
|
May we call you at the last
minute in case of emergency?
|
|
Education
|
|
Degrees/Certifications:
|
|
|
Special Skills/Courses:
|
|
Experience
|
|
|
Please list any training or experience you have working with the elderly.
|
|
|
|
|
|
What would you like most about work with the elderly?
|
|
|
|
Skills
|
|
Have you assisted or performed the following tasks for seniors?
|
|
Companionship:
|
|
|
Bathing/Dressing:
|
|
|
Bathing/Full Assist:
|
|
|
Grooming:
|
|
|
Incontinence:
|
|
|
Transfer Assist:
|
|
|
If Yes:
|
|
|
Laundry:
|
|
|
Alzheimer's Experience:
|
|
|
Driving:
|
|
|
Vacuuming:
|
|
|
Dementia Experience:
|
|
|
Housekeeping:
|
|
|
Incontinent/Full Assist:
|
|
|
Bed Linen Changes:
|
|
|
Grocery Shopping:
|
|
|
Rate Cooking:
|
(1=poor,5=excellent)
|
|
Medication Reminders:
|
|
|
Lifting:
|
|
Applicant's Statement Regarding Caregiving History
|
|
I attest that I, the applicant, have never abused, neglected, sexually assaulted,
exploited or deprived any person nor have I subjected any person to serious injury
as a result of intentional or grossly negligent misconduct.
|
Waiver and Release of Information
|
I understand and agree that any consequential omissions or misrepresentations made
by me on this application will be sufficient cause for cancellation of this application
and/or termination by Homewatch if I have been employed. I understand that any offer
of employment will be at the will of Homewatch and that the company reserves the
right to terminate my employment at any time, with or without prior notice and that
I am free to resign at any time with or without prior notice. I understand that
no representative of the company has the authority to make any assurances to the
contrary.
I give Homewatch the right to investigate all statements contained herein and the
references listed above to give you any and all information concerning my previous
employment and any other pertinent information they may have, personal or otherwise,
and release Homewatch International and its representatives from all liability from
any damage that may result from furnishing the same to you. This includes a criminal
background history, workers compensation investigation and/or social security check.
This may also include random drug testing.
I further agree that I will abide by all the rules, regulations and policies of
Homewatch and that failure to do so may be cause for termination. I also understand
that any offer of employment may be conditioned upon satisfactory completion of
a physical exam or medical evaluation.
|
|
|
|
|
* Full Name:
|
|
|
* Date:
|
|
|
|
|