Your Home Assistant Job Application Name Last Name Email Mobile Phone Address Experience PREVIOUS ASSISTANT/CAREGIVER EXPERIENCE #1 Organization Contact Person Telephone Dates Worked May We Contact? Yes No PREVIOUS ASSISTANT/CAREGIVER EXPERIENCE #2 Organization Contact Person Telephone Dates Worked May We Contact? Yes No PREVIOUS ASSISTANT/CAREGIVER EXPERIENCE #3 Organization Contact Person Telephone Dates Worked May We Contact? Yes No PREVIOUS ASSISTANT/CAREGIVER EXPERIENCE #4 Organization Contact Person Telephone Dates Worked May We Contact? Yes No Professional References (do not include family or friends) REFERENCE #1 Position/Title Telephone Dates Known REFERENCE #2 Position/Title Telephone Dates Known REFERENCE #3 Position/Title Telephone Dates Known Criminal History Have you ever been convicted of any felony or misdemeanor offenses? Yes No If yes, please describe the date and nature of the offense. Education COLLEGE #1 Name Location Major Graduate? Yes No End Date COLLEGE #2 Name Location Major Graduate? Yes No End Date COLLEGE #3 Name Location Major Graduate? Yes No End Date HIGH SCHOOL Name Location Graduate? Yes No End Date General Availability Are you available for all hours? Yes No LIVE-INS Being a Live-In means several consecutive days of care where the Caregiver stays at the care recipient's home for the entire number of days. Are you interested in providing Live-In care? Yes No If yes, choose maximum # of days Skills and Preferences Please check any you are willing to work with Growing Families Companionship Gait Belt Smoking Cats Newborn Children Professionals Incontinence Males Children Bathing/Dressing Driving Females Outpatient Hoyer Lift Transfer Assist Dogs Please check any you have experience with Hoyer Lift Alzheimer's/Dementia Gait Belt Children Incontinence Transfer Assist Specialized Training List any additional certications you hold Additional Questions Do you have access to reliable transportation? Yes No Are you a smoker? Yes No How did you hear about us? Tell us about recent assistant/caregiving experiences. Why do you want to be an assistant with us? Emergency Contact Information EMERGENCY CONTACT #1 Relationship Phone Type Mobile Home Phone Alt Type Mobile Home EMERGENCY CONTACT #2 Relationship Phone Type Mobile Home Phone Alt Type Mobile Home EMERGENCY CONTACT #3 Relationship Phone Type Mobile Home Phone Alt Type Mobile Home CERTIFICATION AND RELEASE I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize COMPANY NAME to verify any and all information contained within this application, 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 and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment. I Agree I Don't Agree RESTRICTIVE COVENANT I agree not to do business directly with any individual or business entity that COMPANY NAME has introduced to me or by entering into employment with such individuals or businesses. I Agree I Don't Agree Send
