Safe at Home Senior Care Application Form
Application Form
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.
Personal Information
First Name
*
Last Name
*
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
City
*
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*
Driver's License Number
--
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Section 1 -
General Information
Social Security Number
Emergency Contact Name
(required)
Phone Number
(required)
Position applying for:
(required)
Are you applying for:
(required)
-- Select an Option --
Full-time work
Part-time work
Temporary work
Would you be able to work overtime if needed?
(required)
Yes
No
If hired what day can you start work?
Salary desired?
If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?
(required)
Yes
No
Are you currently employed?
(required)
Yes
No
If yes, where?
Are you planning on leaving this employer?
Yes
No
If yes, when?
How did you hear about this position with Safe At Home?
Section 2 -
Personal Information
Have you ever applied or worked for Safe At Home Senior Care Inc. before?
(required)
Yes
No
If yes, when?
Do you have any friends or relatives who have worked or are currently working for Safe At Home?
(required)
Yes
No
If yes, state name(s) and relationship
Why would you like to work at Safe At Home Senior Care?
(required)
Are you at least 18 years old?
(required)
Yes
No
Do you smoke?
(required)
Yes
No
Do you have any pet allergies?
(required)
Yes
No
If yes, to what animals?
Have you ever been convicted of a felony, as an adult?
(required)
Yes
No
If yes, state the nature of the crime(s), when and where convicted, and the disposition of the case. (Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offence, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however be considered.)
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Section 3 -
Job Tasks & Duties
Please indicate whether you have assisted with or performed the following tasks for seniors: Companionship
Yes
No
Please indicate whether you have assisted with or performed the following tasks for seniors: Bathing/Dressing
Yes
No
Please indicate whether you have assisted with or performed the following tasks for seniors: Incontinence Care
Yes
No
Please indicate whether you have assisted with or performed the following tasks for seniors: Transfer Assist
Yes
No
Please indicate whether you have assisted with or performed the following tasks for seniors: Personal Care/Hygiene
Yes
No
Do you own a vehicle?
(required)
Yes
No
If yes, what model and make?
Do you have proof of insurance?
Yes
No
How many miles are you willing to travel (one way) from your home to an assignment?
Section 4 -
Cooking Skills
How would you rate your cooking skills? (Check all that apply)
(required)
-- Select an Option --
None
Basic
Gourmet
Vegetarian or Vegan
Dietary restrictions (health related)
Section 5 -
Experience/Abilities
Do you have any experience working with people who have Alzheimers/Dementia?
(required)
Yes
No
Do you have any lifting restrictions?
(required)
Yes
No
If yes, please explain (note: we comply with the ADA and consider reasonable accommodations measures that may be necessary for eligible applicants/employees to perform essential functions.)
Are you comfortable working with female clients?
(required)
Yes
No
Are you able to perform all other job duties for which you are applying for?
(required)
Yes
No
Are you comfortable working with male clients?
(required)
Yes
No
If no, describe the functions that cannot be performed (note: hire may be subject to passing a medical examination and to a skills and agility test)
Section 6 -
Education and Training
High School: (please specify name, address, number of years completed, whether you graduated and if you received a degree or diploma)
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College or University: (please specify name, address, number of years completed, whether you graduated and if you received a degree or diploma)
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Vocational or Business: (please specify name, address, number of years completed, whether you graduated and if you received a degree or diploma)
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Health Care: (please specify name, address, number of years completed, whether you graduated and if you received a degree or diploma)
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What is your first language?
Do you speak, write or understand any foreign languages?
Yes
No
If yes, what language(s)
Do you have any training or experience working with the elderly? (explain)
What would you like most about working with the elderly?
What would you like least about working with the elderly?
(required)
Do you have any other experience, training, qualifications or skills which you feel make you especially well-suited for work at Safe At Home Senior Care?
Section 7 -
Personal References
Name & Relationship
(required)
Phone Number ( )
(required)
How long have you known this person?
(required)
Name & Relationship
(required)
Phone Number ( )
(required)
How long have you known this person?
(required)
Name & Relationship
(required)
Phone Number ( )
(required)
How long have you known this person?
(required)
Section 8 -
Availability
What hours can you work on Sundays?
Can you work Sunday overnights?
(required)
Yes
No
What hours can you work on Mondays?
Can you work Monday overnights?
(required)
Yes
No
What hours can you work on Tuesdays?
Can you work Tuesday overnights?
(required)
Yes
No
What hours can you work on Wednesdays?
Can you work Wednesday overnights?
(required)
Yes
No
What hours can you work on Thursdays?
Can you work Thursday overnights?
(required)
Yes
No
What hours can you work on Fridays?
Can you work Friday overnights?
(required)
Yes
No
What hours can you work on Saturdays?
Can you work Saturday overnights?
(required)
Yes
No
Minimum number of hours desired each week?
Is there anything else you would like us to know about your desired schedule?
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Section 9 -
Employment History
List below all present and past employment starting with your most recent employer (last 5 years is sufficient). Account for all periods of unemployment. You must complete this section even if you submitted a resume). May we contact your current employer?
(required)
Yes
No
Name of Current/Last Employer:
(required)
Address & Phone Number
Type of Business
Supervisor's Name
Your Position & Job Duties
Dates of Employment
Pay Rate
Reason for Leaving or Still Employed
Previous Employment #2: Name of Employer:
Address & Phone Number
Type of Business
Supervisor's Name
Your Position & Job Duties
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Dates of Employment
Pay Rate
Reason for Leaving or Still Employed
Previous Employment #3: Name of Employer:
Address & Phone Number
Type of Business
Supervisor's Name
Your Position & Job Duties
Dates of Employment
Pay Rate
Reason for Leaving or Still Employed
I declare all information on my application for employment provided by me, to Safe At Home Senior Care is true and accurate. Any false or misleading statements or material omissions are grounds to terminate the hiring process or employment, regardless of when discovered.
(required)
Yes
No
I give my consent to Safe At Home Senior Care to perform a background check, including a check for past employment, education and a criminal background check.
(required)
Yes
No
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Signature
Submit Application