Rockford > Caregiver Application

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Caregiver Application

Personal Information

First Name*
Enter your first name.
Middle Name
Last Name*
Enter your last name.

Address*

Enter your address.

City*
Enter your city.
State/Province*
Select your state.
Zip/Postal Code*
Enter a valid zip/postal code.

How long have you lived at this address?*

Enter the time lived at this address.

Enter a valid email.

Home Phone*
Enter a valid phone number.
Business Phone
Enter a valid phone number.
Cell Phone
Enter a valid phone number.

Please List age (if under 18)
Enter a valid age between 0 and 127.
Have you applied here before?* Yes No
Select an option.
Position applied for*
Enter the position you are applying for.

Availability

Please Indicate the days and times you are available to work:

Work Anytime?

Monday (From-To)	Tuesday (From-To)	Wednesday (From-To)	Thursday (From-To)	Friday (From-To)	Saturday (From-To)	Sunday (From-To)

Hourly range desired*

Enter the hourly wage you desire.

How many hours can you work weekly?*
Enter how many hours you can work weekly between 0 and 168.
Are you available to work nights?*
Select an option.
Are you available to work weekends?*
Select an option.

Would you consider live-in?*
Select an option.
Employment desired?*
Select an option.
Are you legally authorized to work in this country?*
Select an option.

When are you available to start work?*

Enter when you are available to start work.

Where did you hear about us?*

Enter where you heard of us.

Education Information

Type of School	Name of School	City	State/Province	Years Completed	Degree	Major
High School*
College
Bus. or Trade School
Professional School

Enter Name of School for High School.

Enter City for High School.

Enter State/Province for High School.

Enter Years between 0 and 127 Completed for High School.

Enter Years between 0 and 127 Completed for College.

Enter Years between 0 and 127 Completed for Trade School.

Enter Years between 0 and 127 Completed for Professional.

For purposes of checking your references and the criminal background check, have you ever worked under a different name?*

Select an option.

If YES, what was it?

Enter the information requested.

Do you have any relatives or friends that work for one of our franchisees?*

Select an option.

If YES, what is their name?

Enter their name.

Transportation Do you have access to reliable transportation such as a car, motorcycle, or public transportation?*

Select an option.

Personal Reference Information

List two personal and two professional references. DO NOT LIST relatives or previous supervisors.

Personal Reference 1

Name*
Enter your reference's name.
Relation*
Select an option.
Company
Enter your reference's company.

Address
Enter your reference's address.
Address 2
City
Enter your reference's city.
State/Province
Select a state.
Zip/Postal Code
Enter a valid zip/postal code.

Telephone (where person can be reached 9am-5pm)*

Enter a valid phone number.

Personal Reference 2

Name
Enter your reference's name.
Relation
Select an option.
Company
Enter your reference's company.

Address
Enter your reference's address.
Address 2
City
Enter your reference's city.
State/Province
Select a state.
Zip/Postal Code
Enter a valid zip/postal code.

Telephone (where person can be reached 9am-5pm)

Enter a valid phone number.

Professional Reference 3

Name*
Enter your reference's name.
Relation*
Select an option.
Company*
Enter your reference's company.

Address
Enter your reference's address.
Address 2
City
Enter your reference's city.
State/Province
Select a state.
Zip/Postal Code
Enter a valid zip/postal code.

Telephone (where person can be reached 9am-5pm)*

Enter a valid phone number.

Professional Reference 4

Name
Enter your reference's name.
Relation
Select an option.
Company
Enter your reference's company.

Address
Enter your reference's address.
Address 2
City
Enter your reference's city.
State/Province
Select a state.
Zip/Postal Code
Enter a valid zip/postal code.

Telephone (where person can be reached 9am-5pm)

Enter a valid phone number.

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.*

Enter the information requested.

Why do you enjoy caregiving?*

Enter why you enjoy caregiving.

Please describe some of your volunteer work:*

Enter a description of some of your volunteer work.

Please list any certifications you currently possess:

Certified Nursing Assistant
Certified Medical Technician
Certified Medicine Aide
CPR Certified
Geriatric Nursing Assistant
First Aid Certification
Certified Home Health Aide
Personal Support Worker

Work Experience

Please list at least two of your work experiences for the past five years beginning with your most recent job held. If you were self-employed, give company name.

Current or Most Recent Employer Information

Employer Name*

Enter the employer's name.

Name of last Supervisor*
Enter the supervisor's name.
Phone Number*
Enter a valid phone number.
Your last job title*
Enter your last job title.

Address
Enter the employer's address.
Address 2
City
Enter the employer's city.
State/Province
Select a state.
Zip/Postal Code
Enter a valid zip/postal code.

Employment Dates

From

Select a month.

Select a day.

Select a year.
To

Select a month.

Select a day.

Select a year.

Reason for leaving (be specific):*

Enter a reason for leaving.

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:*

Enter the information requested.

May we contact your present employer?*

Select an option.

If NO, Please Explain Why and Please Provide Us With Another Work Reference:

Enter the information requested.

Additional Employer Information

Employer Name

Enter the employer's name.

Name of last Supervisor
Enter the supervisor's name.
Phone Number
Enter a valid phone number.
Your last job title
Enter your last job title.

Address
Enter the employer's address.
Address 2
City
Enter the employer's city.
State/Province
Select a state.
Zip/Postal Code
Enter a valid zip/postal code.

Employment Dates

From

Select a month.

Select a day.

Select a year.
To

Select a month.

Select a day.

Select a year.

Reason for leaving (be specific):

Enter a reason for leaving.

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:

Enter the information requested.

May we contact this employer?

Select an option.

If NO, Please Explain Why and Please Provide Us With Another Work Reference:

Enter the information requested.

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
Dressing/Grooming
Select an option.
Meal Preparation
Select an option.
Transferring
Select an option.
Light Housekeeping
Select an option.
Incontinence Care
Select an option.
Bathing/Showering
Select an option.
Dementia/Alzheimer's Care
Select an option.

Set at least one skill with experience.

Comments

In exchange for the consideration of my job application, I agree that:

I CERTIFY that the information contained in this application is correct to the best of my knowledge, and I understand that any misstatement or omission of information is grounds for ending the hiring process or dismissal from employment. I authorize verification of information provided on this application; and authorize the references listed above to give the applicable Senior Helpers’ franchisee all pertinent information concerning my previous employment; and release all parties from all liability for any damage that may result from furnishing the same to a Senior Helpers’ franchisee. I further agree that either I or any Senior Helpers’ franchisee may terminate my employment with or without cause and with or without prior notice, at any time. No representative of Senior Helpers or its franchisees other than an executive officer has the authority to enter into any agreement for employment for any specified period of time. I understand that I may be required to submit to a drug test in accordance with the applicable Senior Helpers’ franchisee’s drug testing policy.

By clicking the submit button I agree to the terms and conditions of this application.

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.