Direct Care Worker Application
Name
*
First Name
Middle Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
*
Gender
*
Please Select
Male
Female
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
I meet the following requirements (check all that apply):
*
Knowledgeable about ages & stages
Stellar references
Reliable & prompt
Able to commit to job timeline
Clear driving record
Safe & ensured vehicle
Can legally work in the U.S.
Current CPR/FA certification or willingness to renew
Speak English
Total number of years experience
*
Are you authorized to work In The United States?
*
Yes
No
Do You Have Reliable Transportation?
*
Yes
No
Are you currently a Direct Care Worker for a potential Edwards Direct Client?
*
Please Select
Yes
No
If you answered "Yes" What is the Clients Name?
First Name
Last Name
Willingness to Travel to
*
Philadelphia County
Montgomery County
Delaware County
Bucks County
Chester County
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Employment Desired:
Date You Can Start
*
-
Month
-
Day
Year
Date Picker Icon
Salary Desired
Position Interested In (check all that apply):
*
Full Time
Part Time
Temporary
On Call
Times Available to Work
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Times Available to Work
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
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Skills/Qualifications:
List three words that describe your personality:
Clients NOT Willing to Work With
*
Elderly (over 65)
HIV Positive/AIDS
Client use of marijuana for medicinal purposes
Other
Duties NOT Willing to Perform
*
Bathing
Grooming
Oral Care
Dressing
Bowel Care
Bladder Care
Feeding
Ambulation
Housekeeping
Laundry
Meal Preparation
Shopping
Transportation
Medical Reminding
Friendly Reassurance Phone Call/Home Visit
Other
Duties Willing to Perform
*
Bathing
Grooming
Oral Care
Dressing
Bowel Care
Bladder Care
Feeding
Ambulation
Housekeeping
Laundry
Meal Preparation
Shopping
Transportation
Medical Reminding
Friendly Reassurance Phone Call/Home Visit
Other
CPR/First Aid Certified?
Please Select
Yes
No
Willing to Get Certified
CPR/First Aid Expiration Date
-
Month
-
Day
Year
Name of CPR/FA instructor:
Phone number for CPR/FA instructor:
Anything else you would like to share:
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Education:
Highest Level of Education:
*
Please Select
High School
College
Graduate School
GED
Other
High School
Name of High School Attended
Graduated High School?
Please Select
Yes
No
College
Name of College/University Attended
Graduated College?
Please Select
Yes
No
Number of Years Attended College
College Area of Study/Degree
Graduate School
Name of Graduate School Attended
Graduated Grad School?
Please Select
Yes
No
Number of Years Attended
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Graduated From Trade School?
Please Select
Yes
No
Number of Years Attended
Area of Study/Degree
List of other professional training:
i.e. STARS, NCS, Doula training, conference workshops, etc.
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Mandatory Job History
Current Employer Name
Current Employer Position
Your job title
Current Employer Salary
Current Employer Start Date
-
Month
-
Day
Year
Date Picker Icon
Current Employer Location
i.e. Neighborhood
Current Employer
Current Employer Duties
Please include an in-depth job description
Current Employer May We Contact?
Yes
No
Please explain why we may not contact your current employer:
Previous Employment
Previous Employer
*
Previous Employer Position
*
Your job title
Previous Employer Salary
*
Previous Employer Start Date
*
-
Month
-
Day
Year
Date Picker Icon
Previous Employer End Date
*
-
Month
-
Day
Year
Date Picker Icon
Previous Employer Location
*
i.e. Neighborhood
Previous Employer Duties
*
Please include an in-depth job description
Previous Employer Reason for Leaving?
*
Previous Employer May We Contact?
*
Yes
No
Please explain why we may not contact your previous employer:
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References:
Please include at least three
May we contact your references?
*
Yes
No
Reference One
*
Name of Reference
Reference One Relationship
*
Reference One Years Acquainted
*
Reference One Phone
*
Reference One Email
*
example@example.com
Reference Two
*
Name of Reference
Reference Two Relationship
*
Reference Two Years Acquainted
*
Reference Two Phone
*
Reference Two Email
*
example@example.com
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Cover Letter & Resume:
Please Upload Your Cover Letter
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Please Upload Your ID
*
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Signature
*
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