Silver Home Care Employment Application

EMPLOYMENT APPLICATION

Personal Care Aide
Thank you for your interest in a Personal Care Aide position with Silver Home Care!

We are a non-medical Home Care Agency that provides in home services to elderly and disabled residents of Bucks and Philadelphia Counties.

At Silver Home Care, our mission is to improve lives!

We value KINDNESS. We show RESPECT for others and we strive to act with INTEGRITY in all that we do.

We are seeking like minded individuals who are FRIENDLY and RELIABLE to help us achieve our mission.

If this sounds like you and you have at least one year of caregiving experience, a drivers licence, and an insured vehicle in good working order, we encourage you to click NEXT.
If you have a referral code, enter it here.
Not required

Employment Application

Personal Care Aide
REQUIREMENTS
- A sincere desire to serve the needs of the elderly and disabled
- 18 years or older
- High School Diploma or GED
- At least 1 year of verifiable experience in a caregiving role.
- A licensed and insured vehicle in good working order
- Successful completion of the Silver Home Care competency exam.
- Proof of Covid-19 Vaccination
Job duties include (but may not be limited to)
- Personal Care
- Medication Reminders
- Meal Preparation
- Laundry
- Housekeeping
- Appointments
- Shopping and Errands
This position involves working with fragile, vulnerable or otherwise dependent individuals in their own homes and under minimal supervision. Therefore, If you are offered a position, we will complete a full background check on you including:
- Drug Testing
- Criminal Records Check
- Child Abuse Clearance
- References (3)
- Proof of Residency
- Medicaid Exclusion List Check
- Social Security Number Verification
If you meet the requirements and would like to apply, please confirm below to proceed to the application.
I am 18 or older I have a valid driver's license I have an insured vehicle in good running order I have a high school diploma or GED I have at least one year of verifiable caregiving experience I can pass a drug test I am fully vaccinated against Covid-19 I can provide at least 3 references who are not related to me that can attest to my character

Employment Application

Personal Care Aide - Demographics
Full Name *

First Name Middle Name Last Name
Home Phone
Cell Phone
Can we text?

Yes No
Address *

Street Address

Street Address Line 2

City State

Zip Code
E-mail *
example@example.com
Are You Legally Eligible to Work in the US? *

Yes No
Years of Caregiving Experience
Do You Have A Valid Drivers License and Vehicle Insurance? *

Yes No
Do You Have a Reliable Vehicle? *

Yes No
What hours and days are you available?
When Can You Start *

Month Day Year
Date

Employment Application

Personal Care Aide - Education
Highest Level of Education Completed *

GED High School Diploma Associates Degree Bachelors Degree or higher
Please select all that Apply:

I am a CNA I am a Nursing Student None of the Above
CNA Registration Number (If Applicable)

Employment Application

Personal Care Aide -Employment History
Are you currently employed?

YES NO
Current Employer *
Current Position *
Current Duties *
Start Date *

Month Day Year
End Date (leave blank if still employed)

Month Day Year
Current Pay Rate *
Current Supervisor *
Supervisor's Phone Number *
Supervisor's Email
May We Contact? *

Yes No

Employment Application

Personal Care Aide -Employment History
Previous Employer 1 *
Name of Previous Employer
Position *
Duties *
Reason for Leaving? *
Ending Pay Rate
Start Date *

Month Day Year
End Date *

Month Day Year
Supervisor *

First Name Last Name
Supervisor's Phone Number *
Supervisor's Email
May we contact? *

Yes No
Would you like to add another employer?

YES NO

Employment Application

Personal Care Aide -Employment History
Previous Employer 2
Name of Previous Employer
Position
Duties
Start Date

Month Day Year
End Date

Month Day Year
Ending Pay Rate
Reason for Leaving?
Supervisor

First Name Last Name
Supervisor's Phone Number
Supervisor's Email
May we contact?

Yes No
Would you like to add another employer?

YES NO

Employment Application

Personal Care Aide - Employment History
Previous Employer 3
Name of Previous Employer
Position
Duties
Start Date

Month Day Year
End Date

Month Day Year
Ending Pay Rate
Reason for Leaving?
Supervisor

First Name Last Name
Supervisor's Phone Number
Supervisor's Email
May we contact?

Yes No

Employment Application

Personal Care Aide -Professional Reference
Would you like to provide additional professional references?

Yes No
Name

First Name Last Name
Company
Phone Number
Email
example@example.com
May we contact?

Yes No
Add Another?

Yes No

Employment Application

Personal Care Aide -Professional Reference
Name

First Name Last Name
Company
Phone Number
Email
example@example.com
May we contact?

Yes No

Employment Application

Personal Care Aide- Authorizations
This authorization gives us permission to contact the references you have provided. Please read carefully.

I have applied for employment with Silver Home Care and have provided information about my previous employment. I authorize Silver Home Care to conduct a reference check with my present and/or previous employer(s). I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary and employment history. My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment to Silver Home Care, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Silver Home Care from any and all liability arising from their giving or receiving information about my employment history or qualifications, and my suitability for employment with Silver Home Care.
Name

First Name Last Name
Date

Month Day Year
Date
Signature

Clear

Employment Application

Personal Care Aide - Drug Test Consent
Successful completion of pre-employment drug testing is a requirement of employment with Silver Home Care. You have the right to refuse this testing but in doing so your application will will be denied. Drug testing will be administered following the completion of your interview if you have been offered a position. We will use an oral swab to collect your saliva to test for the presence of Cocaine, Marijuana, Opiates, Amphetamines, Methamphetamine, and Benzodiazepines. If you are prescribed any medications that may produce a positive result, please notify us in advance of the test. If you believe the results of the test are not accurate, you have the right to request a retest of the original sample at a licensed laboratory of your choice within 3 days.
Full Name *

First Name Middle Name Last Name
I have read and understand the scope, method and policy stated above.

YES NO
I agree to submit to an Oral Swab test to screen for the use of Cocaine, Marijuana, Opiates, Amphetamines, Methamphetamine, and Benzodiazepines.

YES NO
I agree to submit to a drug and alcohol test in the event that I am involved in an accident or other incident where my actions/decisions or lack thereof are potentiallya contributing factor or if drug or alcohol use during work hours is suspected.

YES NO
Date

Month Day Year
Date
Signature

Clear

Employment Application

Personal Care Aide
Tell us how you heard about us and why you are interested in working for Silver Home Care
What do you feel is the most important thing we should know about you?
If you have a cover letter, resume or written references you may upload them here.

NOT REQUIRED
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EMPLOYMENT APPLICATION

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Please provide at least three references who are NOT related to you. Each should have known you for at least 2 years and be able to attest to your character and suitability for this position. Two positive references are a condition of employment.

Employment Application

Employment Application

Employment Application