Senior Helpers McKinney Caregiver Employment Application

Caregiver Employment Application
INSTRUCTIONS: Complete all questions (pages 1-4) Print all information requested except signature. Fax completed application to 469-907-5601 Note: Applicants may be tested for illegal drugs.
Personal Information
Date:
MonthDayYear
Date
Last:*
First:*
Middle:
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
How long at this address?:
Home Phone:
Business Phone:
Cell Phone:*
Please list age (if under 18):
Position applied for:
Have you ever applied here before?
YesNo
Please indicate the days and times you are available to work:
Anytime
Salary range desired:*
How many hours can you work weekly?*
Are you available to work nights?
YesSomeNone
Are you available to work weekend nights?
YesSomeNone
Would you consider live-in?
YesNo
Employment desired?
Part-Time OnlyFull or Part-TimeFull Time Only
Are you legally authorized to work in the US?*
YesNo
When are you available to start work?*
MonthDayYear
Date
Where did you hear about us?*
Email address:*
example@example.com
Marital Status?
SingleMarriedDivorcedWidowed
Social Security:
Education Information
Have you ever worked under a different name?
YesNo
If YES, what was it and what was the reason?
Do you have any relatives or friends that work for the Company?
YesNo
If YES, what is their name?
In Case of Emergency, Please Contact:
Name:
Relation:
Business Phone:
Mobile Phone:
Driving Information
Do you have a valid drivers license?*
YesNo
Do you have auto insurance?*
YesNo
Do you have a car?
YesNo
If no, how would you get to work?
Driver's License No.:
State of Issue:
Expiration Date:
MonthDayYear
Date
Have you had any accidents during the past three years?
NoYes
If Yes, how Many?
Have you had any moving violations during the past three years?
NoYes
If Yes, how Many?
Personal Reference Information
List two personal references. DO NOT LIST relatives or previous supervisors.
Reference 1
Name
Type of Reference
FriendCo-workerTeacherPastorFriendCurrent ClientFormer Client
Company:
Address:
Telephone where person can be reached 9a - 5p
Reference 2
Name
Type of Reference
FriendCo-workerTeacherPastorFriendCurrent ClientFormer Client
Company:
Address:
Telephone where person can be reached 9a - 5p
An application form sometimes makes it difficult to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications to be a caregiver. Please note any experience with caregiving professionally, for your parents, spouse, children or friends. Use additional sheets, if necessary.
Why do you enjoy caregiving?
Describe some of your volunteer work:
Please check any certification(s) you currently possess:
Certified Nursing AssistaneCertified Medication AideGeriatric Nursing AssistanceMedication TechnicianCPR CertificationFirst Aide Certification
Work Experience
1. Name and address of employer:
Name of last supervisor:
Please list at least two of your work experiences in the past five years beginning with your most recent job held. If you were self employed, give company name. Attach additional sheets if necessary.
Employment dates:
MonthDayYear
From
Employment dates:
MonthDayYear
To
Phone number:
Your Last Job Title:
Reason for leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact your present employer?
YesNo
If No, Please Explain Why and Please Provide Us With Another Work Reference:
2. Name and address of employer:
Name of last supervisor:
Employment dates:
MonthDayYear
From
Employment dates:
MonthDayYear
To
Phone number:
Your Last Job Title:
Reason for leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact your present employer?
YesNo
If No, Please Explain Why and Please Provide Us With Another Work Reference:
Skill Information
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience
Companionship
1234
Meal Preparation
1234
Light Housekeeping
1234
Bathing/Showering
1234
Dressing/Grooming
1234
Transferring
1234
Incontinence Care
1234
Dementia/Alzheimer's Care
1234
Comments
APPLICATION FORM WAIVER
Please read carefully
In exchange for the consideration of my job application by Riverstone Care LLC (hereinafter called “Senior Helpers”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Senior Helpers company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Senior Helpers, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President of the Senior Helpers. Both the undersigned and Senior Helpers may end the employment relationship at any time, without specified notice or reason. If employed, I understand that Senior Helpers may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
I also understand that (1) Senior Helpers has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job related physical examinations.
I understand that, in connection with the routine processing of your employment application, Senior Helpers may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, Senior Helpers will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
I hereby release any and all prior employers or current employers from liability or claims arising out of the provision of information about my employment with such employer. I hereby waive any cause of action I might otherwise have against such employer arising out of the provision of information concerning my employment.
I further understand that my employment with Senior Helpers shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with Senior Helpers is terminable at will for any reason by either party.
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Senior Helpers permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release Senior Helpers from any liability as a result of such contract.
Signature of applicant:
Clear
Date:
MonthDayYear
Date
Printed name:
Senior Helpers is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.
Please return this application to our office at your earliest convenience.
1720 W Virginia St Suite B McKinney TX 75069
Phone 469-907-5600
Fax 469-907-5601
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