Apply for Caregiver - Home Instead

Summary
Title:	Caregiver
ID:	1015
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Attachments
Resume:	Supported formats: Word, PDF, RTF, Text, and HTML.

	- or Upload from:


Cover Letter:	You can type in a Cover Letter or Copy/Paste from an existing document.

APPLICANT NOTE

Bishop Senior Care LLC is an independently owned and operated Home Instead® franchise 105 South Pointe Dr., Suite B 618-307-9534.

This application will be valid for 60 days. If you need further assistance for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

This application that you have completed online is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead franchise. This is not an employment contract. Please be sure that you answered all appropriate questions completely and accurately. False or misleading statements during the interview and on your application materials are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law.

CERTIFICATION

I certify that I have read and understand the applicant note above and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application process may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I also understand that the use of illegal drugs is prohibited when carrying out my job responsibilities. I am willing to submit to drug screening if requested to detect the use of illegal drugs prior to and during employment, as allowed under applicable law.

I understand that this application is not a contract for employment.

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date:

BASIC INFORMATION

* Have you ever submitted an application here before?

Yes No

If yes, when?

* Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Yes No

WORK HISTORY

MOST RECENT EMPLOYER

* Are you currently working for this employer?

Yes No

* If yes, may we contact?

Yes No

* Company Name:

* City:

* State:

* Company Phone:

* Dates Employed - From:

* Dates Employed - To:

* Duties:

Reason for Leaving:

REFERENCES

If you are considered for a position, we may contact your references and would ask that you notify them in advance. Please do not list relatives or family/relations.

Professional References

Full Name	Phone Number	Best Time of Day to Call	Email	Relationship (No Relatives)	Number of Years Known
		AM PM
		AM PM

Personal References

Full Name	Phone Number	Best Time of Day to Call	Email	Relationship (No Relatives)	Number of Years Known
		AM PM
		AM PM

APPLICANT NOTE

Bishop Senior Care LLC is an independently owned and operated Home Instead® franchise 105 South Pointe Dr., Suite B 618-307-9534.

This application will be valid for 60 days. If you need further assistance for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

This application that you have completed online is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead franchise. This is not an employment contract. Please be sure that you answered all appropriate questions completely and accurately. False or misleading statements during the interview and on your application materials are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law.

CERTIFICATION

I certify that I have read and understand the applicant note above and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application process may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I also understand that the use of illegal drugs is prohibited when carrying out my job responsibilities. I am willing to submit to drug screening if requested to detect the use of illegal drugs prior to and during employment, as allowed under applicable law.

I understand that this application is not a contract for employment.

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date:

Follow-up questionnaire – caregiving experience

Please indicate those tasks in which you have experience. For the areas that you do not have experience, please note if you are willing to learn.

Tasks	Experience Yes/No	Willing to Learn
Companionship/Conversation	* Yes No	Willing to Learn
Meal Preparation (meals/snacks)	* Yes No	Willing to Learn
Housekeeping (dust, vacuum, laundry)	* Yes No	Willing to Learn
Bathing/showering Assistance	* Yes No	Willing to Learn
Dressing Assistance	* Yes No	Willing to Learn
Showering Assistance	* Yes No	Willing to Learn
Medication Reminders	* Yes No	Willing to Learn
Hospice Care	* Yes No	Willing to Learn
Stroke Care	* Yes No	Willing to Learn
Dementia Care	* Yes No	Willing to Learn
Incidental Transportation & Errands	* Yes No	Willing to Learn
Incontinence Care	* Yes No	Willing to Learn
Personal Care Assistance (Female)	* Yes No	Willing to Learn
Personal Care Assistance (Male)	* Yes No	Willing to Learn
Alzheimer’s or Dementia Care	* Yes No	Willing to Learn
Diabetes Care	* Yes No	Willing to Learn
Hearing Impairment	* Yes No	Willing to Learn
Transferring Assistance (Example: helping a person from chair to standing position)	* Yes No	Willing to Learn
Ambulation Assistance (Example: Ensure a person’s stability and safety when moving)	* Yes No	Willing to Learn
Mechanical Lift (Hoyer Lift)	* Yes No	Willing to Learn

* How many years of experience do you have as a caregiver?

Before you go...