Leaves Application for Employment - Caregiver
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Applicant Information
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Referred by/heard about us through:
*
Position(s) interested in:
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Educational Background
*
Specialized Training/Experience
*
Eligibility Considerations:
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If you answered yes above, please explain:
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Availability and Employment History
Availability Start Date:
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Desired Number of Hours Weekly:
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Have you worked for Leaves Personal Care before?
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Please Select
YES
NO
If yes - What approximate date(s):
Previous Employment
Please List Your Three Most Recent Employers
Employer 1 Name
*
Dates Employed: To/From
*
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Position
*
Reason for Leaving
*
Employer 2 Name
*
Dates Employed: To/From
*
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Position
*
Reason for Leaving
*
Employer 3 Name
Dates Employed: To/From
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Position
Reason for Leaving
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References
Reference 1
*
First Name
Last Name
Position/Title
*
Company
*
Time Known:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Reference 2
*
First Name
Last Name
Position/Title
*
Company
*
Time Known:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Reference 3
First Name
Last Name
Position/Title
Company
Time Known:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Application Authorization
Signature
*
Date
*
-
Month
-
Day
Year
Date
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Interest Survey Questions
What interests you about the Care Companion position?
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What do you feel you would bring to this position?
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What motivates you in life and in work?
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How do you measure success in your work? What would your references say about your work quality?
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Can you provide examples that demonstrate your natural role on a team? How do you encourage those you work with when you disagree on how something should be done?
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Though we cannot guarantee hours, we try to achieve ideal working hours for our caregivers. Let us know approximately how many hours you are looking for at this time.
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Please list your availability:
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Our care companions care for clients in their homes (wherever that may be throughout the greater Grand Rapids area). How far are you willing to travel for client shifts (in minutes or miles)? What cities and towns would you prefer to work in?
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What expectations do you have for wages & benefits?
*
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