• Elite Embrace Home Health Care, LLC

    ELITE EMBRACE HOME HEALTH CARE

  • EMPLOYMENT APPLICATION FOR HOME CARE WORKER

  • SSN

  • Name & Phone Number of Person to contact in the event of an emergency:

  • Job/Employment Application for Direct Care Worker

  • Elite Embrace Home Health Care, LLC

    ELITE EMBRACE HOME HEALTH CARE

  • Do you have current First Aid Certification (State Level):

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  • Do you have current CPR? Have you taken a Food Safety course?

    List any work limitations that you may have and briefly describe:

  • Indicate Days and List Hours Available for Work: Sunday: Monday: Tuesday:

  • From: Saturday: What is the minimum number of hours you will work in one day? What is the maximum number of hours you will work in one day?

  • (Specify) Live-in care usually requires that you to in a client's home continuously for 3-4 days at a time every week. Indicate which shifts you will accept: Weekends: (Friday a.m. to Monday a.m Weekdays (Monday a.m. to Friday a.m

  • Client use of marijuana for medicinal purposes

    Job/Employment Application for Direct Care Worker

  • Elite Embrace Home Health Care, LLC

    ELITE EMBRACE HOME HEALTH CARE

  • (Specify) Housekeeping Laundry Meal Preparation Shopping Transportation Medication Reminding Friendly Reassurance Phone Call/Home Visit Other

  • Do you have a valid Driver's License?

    Are you willing to transport clients in your private vehicle? Do you have adequate vehicle insurance? Are you willing to drive a client's vehicle? Are you willing to escort a client in their own vehicle? Are you willing to escort a client on public transportation?

  • Job/Employment Application for Direct Care Worker

  • Elite Embrace Home Health Care, LLC

    ELITE EMBRACE HOME HEALTH CARE

  • Nature of Friendship (friend, co-worker, family etc (Other than relative

  • Job/Employment Application for Direct Care Worker

  • Elite Embrace Home Health Care, LLC

    ELITE EMBRACE HOME HEALTH CARE

  • I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to Elite Embrace Home Health Care, LLC and I hereby release and discharge any of the above and Elite Embrace Home Health Care, LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary

    Iagree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check

    If further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.

  • Clear
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  • Job/Employment Application for Direct Care Worker

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