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

2.No

13. Have you ever worked as a caregiver or served as a volunteer?

1.Yes

2.No

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

2.No

15. Have you completed a certification program to become a Certified Nursing Aide or Home Health Aide?

1.Yes

2.No

16. Are you trained in assisting and interacting with seniors suffering from memory loss, including Alzheimer’s Disease?

1.Yes

2.No

17. Are you trained in CPR?

1.Yes

2.No

18. Do you know how to safely use a gait belt?

1.Yes

2.No

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

2.No

20. Have you successfully passed a multi-state criminal background check for a former employer or have verification of passing one?

1.Yes

2.No

21. Have you worked as a caregiver for a year or more?

1.Yes

2.No

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

SUNSHINE ELDERLY CARE

EMPLOYEE APPLICATION