INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment

process, please notify the person who gave you this form and every reasonable effort will be made to

meet your needs in a reasonable amount of time

• Please read "Applicant Note" below.

• Complete all pages of this application.

• Print clearly. Incomplete or illegible applications may not be accepted.

• If more space is needed to complete any question, use comments section on the back.

• Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for

employment with our Home Care Agency. This is not an employment contract. Please answer all

appropriate questions completely and accurately. False or misleading statements during the interview

and on this form are grounds for terminating the application process or, if discovered after employment

begins, terminating employment. All qualified applicants will receive consideration and will be treated

throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or

any other protected class status under applicable law. Additional testing for the presence of illegal drugs

in your body may be required prior to employment.

Personal Information

Your Availability

Due to the nature of the business, no guarantee can be made as to the schedule or the number of hours worked.

Preferences

Please indicate all areas of the city in which you are willing to work:

*In order to be able to provide transportation or run errands, you will be required to have a valid driver's license and current auto insurance. A motor vehicle record check will be conducted, and proof of insurance will be required.

Job Related Skills

Education

For employment our minimum education requirement is either a GED or High School Diploma.  Please circle the highest grade completed. Grade School 6 7 8 - High School: 9 10 11 12 - College 13 14 15 16 16+

Work History

Your application will not be considered unless all questions in the section are answered.  Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Most Recent Employer:

Second Most Recent Employer:

Security

*** Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.

References ( Do not include relatives)

Please complete all 6 references.  Your application will not be considered unless 6 references are provided. Since we will contact these references, please notify them in advance.  If we are unable to reach all 6 references, you will be asked to provide additional references.

APPLICANT NOTICE:

It is illegal in Philadelphia for employers to ask about your criminal background during the job application process.

Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depend on the results of your background check).

• Criminal convictions can be considered ONLY if they occurred less than 7 years from when you apply (not counting time of incarceration).
• Arrests that did not lead to conviction cannot be used in any employment decisions.
• If your background check reveals a conviction, the employer must consider: The type of offense and the time that has passed since it occurred. Its connection to the job you're applying for; and
• Your job history, character references, and any evidence of rehabilitation.
• Employers can reject you based on your criminal record ONLY if you pose an unacceptable risk to the business or to other people.
• If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision.
• You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation.

APPLICANT CERTIFICATION AND RELEASE:

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers

given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.

I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations.

 

I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

DIRECT CARE WORKER AVAILIBILITY FORM

Please complete the folowwing schedule and provide times that you are able to work for GHHC. We provide services 24 hours a day, 7 days a week.  How you complete this form is very important.  The work hours that are provided for you by GHHC are driven by two primary factors; the needs of the Patients and your availability to work.

** I understand that the more I am available to work the greater the likelihood that my hours request will be met.

This sheet designates the times that I am committing myself to be available to work for GHHC. By signing this sheet, I acknowledge that the decision to hire me will be based in part on the above availability. I agree any changes to my availability must be approved and signed by my supervisor. I understand that there is no guarantee of hours if I am offered a position with GHHC. I understand that it can take time to reach and sustain my desired number of hours per" week and that multiple factors affect this goal including my availability, Patient requests, my stalls, and my ability to please the Patient to whom I am assigned. Nothing in this statement is to be construed as a direct, implied or inferred contract of employment. I understand I am not authorized to provide medical care independently and agree that if a medical emergency arises while I am with a Patient, I will call 911 and follow their instructions accordingly.