Caregiver's application (Dream Home Care )

Employment with us
Have you ever applied here before ?*

YesNo
Have ever been employed here before ?*

YesNo
Did you receive the copy of the job description ?*
Are you able to perform the essential functions of the job for which you are applying with or without a Reasonable accommodation? *
Are you willing to work weekends and overtime? Yes/ No*
Are you Legally authorized to work in the United States? Yes/ No *
Why are you interested in employment with us? *
How did you hear about us ?*

Job Related Skills
Describe any training or life skills you have that apply to caring for a senior: *
Describe any work history you have that would apply to caring for a senior: *
What do you like (or think you would like) most about working with older adults? *
What personal rewards do you get from working with seniors?
What do you like (or think you would like) least about working with older adults?

Education
What is the highest level of education that you received?*

High SchoolCollege / university
School Name
Years Attended
Graduated

YesNo
College / university Name
Years Attended
Major of Study
Graduated ?

YesNo

Security
Are you at-least 18 years of age ? *
List the states and counties of residence for past 7 years: *
Have you ever had traffic violation ?*
If yes describe below:
Have you ever been charged/convicted of a felony or misdemeanor/ or served time? *
If yes describe below:
Have you ever been a charged perpetrator or appeared on any child abuse registry in last 5 years ?*
Have you been convicted of a crime in the last 5 years related to a home care agency?*
If yes describe below:

Family Demography

Please list a family member below, (parents, children, spuse)
Full Name*
Age*
Gender
Phone Number*
Please enter a valid phone number.
Relationship*
Years Known

References

Please write down list of 2 persons who have knowledge about you work performance. (Cannot be Family Member or relative)
Reference 1

Please include Atleast Name, address and phone number
Full Name*
Address include city, zip code and State*
Relationship to you*
Phone Number*
Email
example@example.com

Reference 2

Please include Atleast Name, address and phone number
Full Name*
Address include city, zip code and State*
Relationship to you*
Phone Number*
Email
example@example.com
By signing below I acknowledge that I have read and understand the attached policy *

Clear

Hepatitis vaccine acknowledgement ?
I understand that I might have been exposed to of Hepatitis B In that case, the agency will give an opportunity to for me to get one at any cost. I understand that it is my decision to choose to receive it or waive it. I want to:*

Receive Hepatitis VaccineRefuse the hepatitis vaccine and I do understand the risk of it.
Should be Empty:

Form