
SUNSHINE ELDERLY CARE
SUNSHINE ELDERLY CARE
EMPLOYEE APPLICATION
EMPLOYEE APPLICATION
PERSONAL INFORMATION
First Name: ________________ Last Name_________________ Middle Initials___________
Address________________________________ City____________ State______________ Zip__________
Years at address? __________
Previous Address______________________________ City:___________ State______________ Zip__________
Years at address? ______
Home Phone________________ Cell Phone:________________ Email:______________________
Social Security Number: ____________________________ Date of Birth: _______/______/_______month/day/year
Are you a Citizen?[ ] Yes [ ] NO Have you ever been convicted of any crime? Yes ______ No ______
EDUCATION AND TRAINING
School Name_____________________ Location__________________ Year Attended_________
Degree Received / Certificate Obtained Major_____________________________________
Other training, certifications or licenses held: ______________________________________________________
Do you have a High School Diploma? [] Yes [ ] No OR G.E.D [ ] Yes [ ] No
Position applying for, be specific: Desired Salary Date available for work
____________________________________$________________ ___________________Per hour (month/day/year)
State fully why you believe you are qualified for this position:
__________________________________________________________________________________
___________________________________________________________________________________________
ARREST RECORD
Have you been arrested within the last 5 years? [] Yes [] No
Have you been convicted of a felony or misdemeanor within the last 5 years? [] Yes [] No
Describe_______________________________________________________________________
______________________________________________________________________________
REFERENCES
Name: ______________________________________________
Occupation __________________________________________
Address: ____________________________________________________________________________
Street City State Zip
Telephone Contact ______________________ Email: _______________________________________
Name: ______________________________________________
Occupation __________________________________________
Address: ____________________________________________________________________________
Street City State Zip
Telephone Contact______________________ Email: _______________________________________
Name: ______________________________________________
Occupation __________________________________________
Address: ____________________________________________________________________________
Street City State Zip
Telephone Contact ______________________ Email: _______________________________________
PLEASE ANSWER THE QUESTIONS BELOW:
1. Why should we hire you?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
2. What are your goals and aspirations?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Why did you leave your last job?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
4. What would you do if you encounter problems with client or family members while on the job?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
5. In case of a fall, a cut, or you are unable to find a client(wandered off), What would you do? ______________________________________________________________________________________________________________________________________________________________________________________________________________________
6. In case of an emergency that occurs with client while in your care, What would you do?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
7. If a client(s) or family asked you to do chores that you are entitled to, what would you do?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
8. If there is a change in the client medication, or the aide before you forgot to give the client his/her medication, what would you do?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
9. Would you treat all clients the same?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
10. If you overheard conversations within the household where the client resides, and it seems surprising, what would you do?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
11. On most if not all of our jobs, our clients required meal preparations, can you cook?
___________________________________________________________________________________________________________
You have completed the first half of the quiz, now please answer the yes and no questions below:
12. Do you have experience assisting a senior or someone with a disability with care needs such as meal preparation, bathing, dressing, running errands, or performing household chores?
1.Yes
13. Have you ever worked as a caregiver or served as a volunteer?
1.Yes
14. Have you ever known anyone or assisted anyone with an age-related disease such as Alzheimer’s Disease, Parkinson’s Disease, Multiple Sclerosis, ALS, or Stroke?
1.Yes
15. Have you completed a certification program to become a Certified Nursing Aide or Home Health Aide?
1.Yes
16. Are you trained in assisting and interacting with seniors suffering from memory loss, including Alzheimer’s Disease?
1.Yes
17. Are you trained in CPR?
1.Yes
18. Do you know how to safely use a gait belt?
1.Yes
19. Do you know how to safely transfer and position someone from bed to chair to wheelchair to commode and back, including using a draw sheet and slide board, if necessary?
1.Yes
20. Have you successfully passed a multi-state criminal background check for a former employer or have verification of passing one?
1.Yes
21. Have you worked as a caregiver for a year or more?
1.Yes
PLEASE INDICATE DAYS AND HOURS YOU ARE AVAILABLE TO WORK
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Day:
Night:
I agree, in consideration of you employing me, that I will not seek or accept employment either directly or indirectly, in this state or any other, from any client of Sunshine Elderly Care, LLC, for at least four months after your official date of employment resignation or termination. If this agreement is broken, I solely agree to pay Sunshine Elderly Care, LLC damages of one-month client fees.
I agree that the information contained in this agreement form is correct to the best of my knowledge and understand that any misstatement or omission of information may result in denial of employment. I swear that all personal information and authorization to conduct a background check is given to Sunshine Elderly Care, LLC has been voluntarily given by me.
_________________________________ _________________
Applicant signature (Print name) Date