COMFORT HEALTH DSP JOB OPPORTUNITY FORM

1
Hi! What is your name?* This field is required.Please spell it according to your full legal name
Miss
Mr.
Mrs.
Ms.
Prefix
First Name
Last Name
2
DOB* This field is required.
Date
Month
Day
Year
3
SSN#Social Security Number. It is important to fill out this information for a faster approval process.
4
Home address* This field is required.
Street Address
Apt or Unit #
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Home #
Please enter a valid phone number.
6
Cell #* This field is required.
Please enter a valid phone number.
7
Do you have text?* This field is required.
YESNO
8
Fax #
Please enter a valid phone number.
9
Email address
example@example.com
10
Do you have a driver's license?* This field is required.
YESNO
11
Do you have a car you can use for the job?* This field is required.
Yes
No
Sometimes
12
Are you a student?* This field is required.
YESNO
13
From which school?* This field is required.
14
Which High School / Yeshiva did you graduate from?* This field is required.
15
What year did you graduate?* This field is required.
16
Do you have a diploma?* This field is required.
YESNO
17
Which diploma?* This field is required.
High School
BA
Masters
18
Which languages do you speak fluently?* This field is required.
English
Yiddish
Hebrew
Russian
Spanish
Creole
French
Polish
19
What's your first language?* This field is required.
English
Yiddish
Hebrew
Russian
Spanish
Creole
French
Polish
20
What neighborhood are you available to work in?* This field is required.
Boro Park
Flatbush
Kensington
Staten Island
Williamsburg
Crown Heights
The Five Towns
Bronx
Bensonhurst
Manhattan
Canarsie
Queens
21
Can you work short term or long term?* This field is required.
Short term
Long term
22
Do you have prior experience working with children? * This field is required.
YESNO
23
Specify if you’ve worked with mainstream or special needs children* This field is required.
Mainstreamed
Special needs
24
Tell us more about your work experience
Huge
Large
Normal
Small
Ok
Ok
25
What hours are you available to work?* This field is required.
7AM – 9AM
9AM – 12PM
12PM – 2PM
2PM – 4PM
4PM – 6PM
6PM – 8PM
8PM - 10PM
Overnight
Shabbos
26
Choose the amount of hours you’re available weekly:* This field is required.
2-10
10-20
20-30
30-40
27
Which days are you available?* This field is required.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
28
Where do you prefer to work with your client?* This field is required.
Individual’s home
Out of individuals home
29
Which activities do you enjoy or prefer to do with your client?* This field is required.
Homework
Skill practice
Recreational activities
Entertaining
Shadowing
30
If you can contribute through your unique talent, please specify:
Music
Art
Cooking\Baking
Sports
Gymnastics
Exercise
Crafts
Social skills training
Sewing
Home organizer
31
Gender preference* This field is required.
Male
Female
32
Age preference* This field is required.
0-3
4-7
8-12
13-16
17-21
21+
Any
33
Preferred communication* This field is required.
Phone call
Email
Text
34
Preferred channel for transferring necessary information:* This field is required.
In person
Mail
Fax
Email
35
Were you referred to Comfort Health by someone?
YESNO
36
Reference name:* This field is required.
First Name
Last Name
37
Reference Phone Number* This field is required.
Please enter a valid phone number.
38
How did you hear about us?
Advertisement
Family/friend
Online
39
Any comments?
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Large
Normal
Small
Ok
Ok
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