Professional Caregiver Employment Form

Employment Form

we are an equal opportunity employment, dedicated to a policy of non-discnimination in employment on any basis including race, colon, age sex, religion, disability, medical condition, national origin, on marital status.

What area are you applying for?*
- Warsaw Area
- Fort Wayne Area
Name*
First Last
Home Phone*
Mobile Phone
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Diver's License Number
Social Security Number
Section 2
Have you ever worked with Season HomeCare previously?*
- Yes
- No
Have you ever had experience related to caregiving?*
- Yes
- No
Do you have any relevent certifications or licenses?*
- Yes
- No
Please list certifications or licenses held.
Are you available for overnighters?*
- Yes
- No
Have you ever been convicted of a criminal offense?*
- Yes
- No
If yes, please explain.
Section 3
Employer Address
Employer Phone
Position Held
Start Date
End Date
Second Employer Name
Second Employer Phone
Second Employer address
Position Held
Start Date
End Date
Name and Phone Number
Name and Phone Number
Name and Phone Number
Section 4 - Personal Preferences and Abilities
How many pounds can you lift without assistance? (Numeric Answers Only)
Have you ever had training or experience with Alzheimer's or Dementia?
- Yes
- No
If yes, when and where?
Have you ever had training or experience for bed bound individuals?
- Yes
- No
If yes, when and where?
Have you ever had training or experience transferring an individual ie: from a bed to a wheelchair?
- Yes
- No
If yes, when and where?
Have you had experience or training in bathing another person?
- Yes
- No
If yes, when and where?
Are you willing to be with someone who has a dog?
- Yes
- No
Are you willing to be with someone who has a cat?
- Yes
- No
Are you willing to be with someone who smokes?
- Yes
- No
Does your car insurance cover transporting others in your car in the course of business?
Have you received any training or have any experience in caring for an individual who needs assistance?
- Yes
- No
Section 5 - Additional Information
ls there any additional information you would like us to consider for employment with our company?
How did you hear about us?
I centify that infonmation contained in tfris ailpfiJation is tnue and complete. f unaerltand that false infonmation may be grounds for not hinin$ me on fon immediate tenmination of empfi-oyment at any point in the futune if I am hined. I authonize the verification of any or all information listed above.

Professional Caregiver Employment Form

Employment Form

Section 2

Section 3

Section 4 - Personal Preferences and Abilities

Section 5 - Additional Information