This job position involves assisting clients with activities of daily living in their home.  Duties may include assistance with personal care, light housekeeping, meal preparation, transportation for errands and MD appointments, medication reminders, companionship, etc.  Duties will vary from client to client.

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Personal Details

*First Name

*Last Name

Gender

Male     Female    

Date of Birth

Are you bilingual in any other languages? If so, what?

Contact Details

Address

Address 2

City

Zip Code

Email

*Home Phone

Cell Phone

I am applying for a position as:

An Hourly CNA.     An Hourly HHA.     An Hourly Caregiver.     A Home Care Aide.    

CNA, HHA, Home Care Aide Certification #

Referred by/source

Emergency Contact

Name

Phone Number

Relationship

Additional Details

Have you ever been convicted of a felony?

Yes     No    

Have you ever been convicted of a misdemeanor

Yes     No    

If yes to either, please provide details

Transportation

Do you have a California Drivers License?

Yes     No    

Drivers License #

Do you have dependable transportation?

Yes     No    

Number of hours you would like to work

Availability

Would you like a live-in situation? (3 or 4 days a week)

Yes     No    

Times you ARE available to work

Time NOT available to work

May we call you last minute in case of an emergency?

Yes     No    

High School Education

High School Name

High School City/State

Dates Attended High School

Did you earn a Diploma?

Yes     No    

College/University Education

College/University Name

College/University City/State

Degree Earned

Dates you attended College/University

Other Schools

Other School Name

Other School City/State

Degree/Certification Earned

Credentials

Registered Home Care Aide

Yes     No    

If yes, Home Care Aide ID Number

CPR Certification

Yes     No    

Fire Safety Card

Yes     No    

Experience

Describe training or experience working with the elderly

What do you like the most about working with the elderly?

What do you like least about working with the elderly?

Skills

Please check all that you are experienced with

Companionship.     Bathing/Dressing/ Bathing/Full Assist.     Grooming.     Incontinence.     Transfer Assist.     Lifting.     Vacuuming.     Dusting.     Dementia Experience.     Alzheimer Experience.     Housekeeping.     Bed Linen Changes.     Laundry.     Grocery Shopping.     Cooking.     Driving.     Medication Reminders.    

What are your 3 greatest strengths?

Employment History

May we contact your current employer?

Current Employer

Name of Company

Job Title

Duties

Supervisor Name/ Phone Number

Previous Employer

Name of Company (previous)

Job Title (previous)

Duties (previous)

Supervisor Name/ Phone Number (previous)

Dates Worked at Location

Employment/ Work/ Business References

Reference Name (#1)

Company (#1)

Relationship (#1)

Years Known (#1)

Phone Number (#1)

Reference Name (#2)

Company (#2)

Relationship (#2)

Years Known (#2)

Phone Number (#2)

Personal References

Name (Personal Reference #1)

City/State (Personal Reference #1)

Relationship (Personal Reference #1)

Years Known (Personal Reference #1)

Phone Number (Personal Reference #1)

Name (Personal Reference #2)

City/State (Personal Reference #2)

Relationship (Personal Reference #2)

Years Known (Personal Reference #2)

Phone Number (Personal Reference #2)

*I certify that all information is true and complete I understand that any misleading or incorrect statements render this application void and may be cause for termination I herby authorize Affective Healthcare, Inc or its designees, to make su

Yes     No    

Fields with (*) are compulsory.