Employment

Applicant Information

Full Name:

Last

First

M.I.

Date:

Address:

Street Address

Apartment/Unit #

City

State

Zip Code

Phone:

Email:

Date of Birth:

Social Security No:

Desired Salary:$

Position Applied for:

Are you currently employed

Yes

Are you currently enrolled in school?

Yes

Do you have at least 1 year of working experience as a Care Giver?

Yes

Do you have a reliable source of transportation?

Yes

Are you a citizen of the United States?

Yes

If no, are you authorized to work in the U.S.?

Yes

Have you ever worked for this company?

Yes

If yes, when?

Have you ever been convicted of a felony?

Yes

If yes, explain:

Please select the service areas that you are available to work in:

Area 1	Area 2	Area 3	Area 4	Area 5	Area 6
La Verne Montclair Claremont Chino Chino Hills	Ontario Rancho Cu. Fontana Bloomington	Rialto San Bernardino Highland Colton Redlands Loma Linda	Beaumont Cherry Valley Banning Moreno Valley Yucaipa Mentone Calimesa	Victorville Apple Valley Hesperia	Riverside Corona Norco Temecula Perris Lake Elsinore

Area 1

Area 2

Area 3

Area 4

Area 5

Area 6

La Verne

Montclair

Claremont

Chino

Chino Hills

Ontario

Rancho Cu.

Fontana

Bloomington

Rialto

San Bernardino

Highland

Colton

Redlands

Loma Linda

Beaumont

Cherry Valley

Banning

Moreno Valley

Yucaipa

Mentone

Calimesa

Victorville

Apple Valley

Hesperia

Riverside

Corona

Norco

Temecula

Perris

Lake Elsinore

Education

High School:

Address:

From:

To:

Did you graduate?

Yes

Diploma:

College:

Address:

From:

To:

Did you graduate?

Yes

Diploma:

Other:

Address:

From:

To:

Did you graduate?

Yes

Diploma:

Previous Employment

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:$

Ending Salary:$

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:$

Ending Salary:$

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:$

Ending Salary:$

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

Requirements and Availability

Are you Registered with the Home Care Aide?

Yes

Have you had a Live Scan Fingerprint done?

Yes

Are you CPR & First Aid Certified?

Yes

Have you had a TB Vaccination within the last two years?

Yes

What is your availability?

Monday AM	Tuesday AM	Wednesday AM	Thursday AM	Friday AM	Saturday AM	Sunday AM
From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open

Monday PM	Tuesday PM	Wednesday PM	Thursday PM	Friday PM	Saturday PM	Sunday PM
From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open

Use the following chart for days and times you are not available

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open	From: To: Open

Special Availability Notes:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature:

Date:

References

Please list five professional or personal references.

1.) Full Name:

Relationship:

Phone:

Email:

2.) Full Name:

Relationship:

Phone:

Email:

3.) Full Name:

Relationship:

Phone:

Email:

4.) Full Name:

Relationship:

Phone:

Email:

5.) Full Name:

Relationship:

Phone:

Email:

Employee’s Name:

Please List 3 Emergency Contacts

1.) Full Name:

Relationship:

Phone:

Email:

2.) Full Name:

Relationship:

Phone:

Email:

3.) Full Name:

Relationship:

Phone:

Email:

Please check off if you have experience with any of the following:

Dementia

Alzheimer’s

Stroke

Diabetes

Mentally Disabled

Hospice

Incontinence

1. List some important things you need to know when working with patients who have Dementia, Alzheimer’s, Stroke, or Diabetes.

2. Describe what you would do if you had a dementia patient who see’s little green people, and he gets anxious because he thinks they are coming for him so he tries to get away, and falls. Now blood is gushing from his head. What do you do?

3. Do you have certifications or other information you would like us to know about?

Yes

If yes, please list below:

4. How do you transfer a client safely?

5. What is the most important thing you have learned as a caregiver?

Caregivers Skills List

Do you have experience with any of the following?

Level 1

Companionship

Cooking/Meal Preparation

Light Housekeeping

Out of Home Activities

Dr. Appt./Errands/Shopping

Light Exercise

Monitor/Wandering

Medicine Reminders

Level 2

Feed

Bath/Shower/Sponge

Dress/Groom

Ambulation

Cane/Walker/Wheel Chair/Scooter

Toileting

Gait

Fall Risk

Level 3

Feeding Tube

Transfers

Hoyer

Wears Briefs

Dementia

Wound Care

Hospice Care

Ext.

Ok with pets

Ok with smoking

Reliable Transportation

Has own car

Will work Live in Shifts

Max client weight: