Silver Home Care Direct Care Worker Application

Direct Care Worker Employment Application

Education
Highest Level of Education Completed
Please select all that Apply:
CNA Registration Number (If Applicable)

Direct Care Worker Employment Application

Employment History
First Name
Last Name
Are you currently employed?
Current Employer
Current Position
Current Duties
Start Date

MonthDayYear
End Date (leave blank if still employed)

MonthDayYear
Current Pay Rate
Current Supervisor
Supervisor's Phone Number
Format: (000) 000-0000.
Supervisor's Email
By providing an email address here, you are authorizing us to contact this individual by email.
May We Contact?
Would you like to add another employer?

Direct Care Worker Employment Application

Employment History
Previous Employer 1
Name of Previous Employer
Position
Duties
Reason for Leaving?
Ending Pay Rate
Start Date

MonthDayYear
End Date

MonthDayYear
Supervisor

First NameLast Name
Supervisor's Phone Number
Supervisor's Email
By providing an email address here, you are authorizing us to contact this individual by email.
May we contact?
Would you like to add another employer?

Direct Care Worker Employment Application

Employment History
Previous Employer 2
Name of Previous Employer
Position
Duties
Start Date

MonthDayYear
End Date

MonthDayYear
Ending Pay Rate
Reason for Leaving?
Supervisor

First NameLast Name
Supervisor's Phone Number
Supervisor's Email
By providing an email address here, you are authorizing us to contact this individual by email.
May we contact?

Direct Care Worker Employment Application

Professional Reference
Would you like to provide additional professional references?
Name

First NameLast Name
Company
Phone Number
Format: (000) 000-0000.
Email
By providing an email address here, you are authorizing us to contact this individual by email.
May we contact?
Add Another Professional Reference?

Direct Care Worker Employment Application

Additional Professional Reference
Name

First NameLast Name
Company
Phone Number
Format: (000) 000-0000.
Email
example@example.com
May we contact?

Direct Care Worker Employment Application

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 NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature - Please Sign Legibly
Type your name to confirm signature
First Name
Last Name

Drug Testing 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 collect your salive or urine 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 NameMiddle NameLast Name
I have read and understand the scope, method and policy stated above.
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.
I agree to submit to urine test or oral swab test to screen for the use of Cocaine, Marijuana, Opiates, Amphetamines, Methamphetamine, and Benzodiazepines.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Type your name to confirm signature
First Name
Last Name
Note: You must agree to a drug test by answering the above 3 questions with a "YES" in order to be eligible for employment

Direct Care Worker Employment Application

Employment History
Previous Employer 3
Name of Previous Employer
Position
Duties
Start Date

MonthDayYear
End Date

MonthDayYear
Ending Pay Rate
Reason for Leaving?
Supervisor

First NameLast Name
Supervisor's Phone Number
Supervisor's Email
By providing an email address here, you are authorizing us to contact this individual by email.
May we contact?
Acknowledgement of At Will Statement
Type your name to confirm signature
First Name
Last Name

Employment Application

Direct Care Worker
As a Community Health Choices provider, Silver Home Care is pleased to offer our Friends and Family Program. This program allows you to provide care for an eligible family member or loved one while receiving training and support from our agency.
Are you applying to provide care to a family member or loved one who is an existing or soon to be client of this agency?
Enter the name of the client

First NameLast Name
Do you hold any of the following roles in regards to this individual (select all that apply)
Please Be Advised: You've indicated that you hold a legal role for the client you wish to care for. As per Pennsylvania state regulations and Silver Home Care policies, you are not eligible to provide direct care for this specific client while holding this designation. However, if you wish to proceed with this application, you are welcome to apply to work with other clients within our agency.
Attestation:
I hereby affirm and attest that I do not hold any of the following legal roles—Power of Attorney, Appointee, Guardian, Authorized Representative or other Legal Representative—for the client named above. I understand that should I take on any of these roles while employed by Silver Home Care, I am obligated to promptly report this change in status to the agency. Furthermore, I acknowledge that assuming any of these roles will be treated as a voluntary resignation from my position, in compliance with Pennsylvania state regulations and Silver Home Care policies.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type your name to confirm signature
First Name
Last Name

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

NOT REQUIRED
Cancelof
I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Owner, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Silver Home Care, except in a specific written contract of employment signed on behalf of the organization by its Owner, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.
Please Sign:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type your name to confirm signature
First Name
Last Name
Please enter your name to confirm your signature

First NameLast Name
Should be Empty:

Employment Application

REQUIREMENTS

Direct Care Worker Employment Application

Direct Care Worker Employment Application

Direct Care Worker Employment Application

Direct Care Worker Employment Application

Direct Care Worker Employment Application

Direct Care Worker Employment Application

Direct Care Worker Employment Application

Direct Care Worker Employment Application

Direct Care Worker Employment Application

Drug Testing Consent

Direct Care Worker Employment Application

Employment Application