Caregiver Application Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you over 18 years of age? * Yes No Are you legally eligible to work in the United States? * Yes No How flexible are you to cover shifts and substitute for teammates, outside of your regular work schedule? * Highly Flexible Somewhat Flexible Rarely Flexible Never Flexible Please list all days and hours you are available to work. * Our night shifts are awake shifts. If applying for a night shift, do you foresee any difficulty remaining awake and alert for the entire shift? * Yes No N/A Do you have reliable transportation? * Yes No Date Available to Start * MM DD YYYY Expected Salary $ This position requires working some holidays and may require overtime, weekend work, and staying on shift until your relief arrives. Do you foresee any problems fulfilling these requirements? * Yes No If "Yes", please explain Are you able to work the following shifts? * Days: 7am – 3pm Swings: 3pm – 11pm NOC: 11pm – 7am PRN If you have any plans/appointments in the next three months that would conflict with your work schedule, please provide important information. Employment History Are you currently employed? * Yes No Please list present and past employment starting with your most recent employer: 1. Employer/Company Name Dates Employed Supervisor’s Name Supervisor’s Contact Info Can we contact this employer? Yes No 2. Employer/Company Name Dates Employed Supervisor’s Name Supervisor’s Contact Info Can we contact this employer? Yes No 3. Employer/Company Name Dates Employed Supervisor’s Name Supervisor’s Contact Info Can we contact this employer? Yes No Education Please list present and past education starting with the most recent school: 1. Name of School Certification or Degree Earned Field of Study Year of Completion 2. Name of School Field of Study Certification or Degree Earned Year of Completion 2. Name of School Field of Study Certification or Degree Earned Year of Completion Skills & Abilities Are you restricted from lifting specific weights? * Yes No If "yes", please specify in pounds. Have you dealt with incontinence (both bowel and bladder) and used incontinence products on any of your previous jobs? * Yes No This job requires you to transfer residents from bed to wheelchair and from wheelchair to bed or toilet or chair. Do you have any physical limitations that would prohibit you from task? Yes No Is there any phase of housekeeping that you cannot do or are unwilling to do? * Yes No If "Yes", please explain. How would you describe your housekeeping skills (laundry, cleaning bathrooms, floors, etc.)? How would you describe your skills in preparing meals/cooking? What other skills/abilities do you have that pertain to this position? References 1. Name Relation Email Phone Number 2. Name Relation Email Phone Number 3. Name Relation Email Phone Number Employee Credentials Check the boxes of your current credentials: CNA License HCA License CPR Card First Aid Card Background Check HIV/AIDS Certificate 2 Step Tb (step 1 within 3 days of hire) Fingerprint Check (within 7 days of hire) Food Handler’s Card Nurse Delegation Certificate Diabetic Delegation Certificate Dementia Certificate Mental Health Certificate What else would you like us to know about yourself? To the best of my knowledge, the information I have provided in this application is true and accurate. I understand that if I am offered a job with your company, accept it, and later it is determined that my answers to any of the above questions are not truthful; I may be dismissed from employement. Electronic Signature * Date of Signature MM DD YYYY How did you hear about this open position? Craigslist Zip Recruiter Indeed Tacoma Weekly Friend / Family Other If other, please specify Thank you!
