GAHC Services - Care Giver Job Application Form

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Applying for Position* This field is required.
Please Select
Please Select
In-Home CareGiver
HHA (Home Health Aid)
HCA (Health Care Assistant)
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Full Name* This field is required.
First Name
Middle Name
Last Name
3
Email Address* This field is required.
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Phone Number* This field is required.
5
Current Address* This field is required.
Street Address
Street Address Line 2
City
County
Postcode
Please Select
Please Select
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
United States
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
6
Are you at least 18 years of age?* This field is required.
YESNO
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Date of Birth* This field is required.
Date
Month
Day
Year
8
What is your desired hourly rate?* This field is required.
9
Are you legally authorized to work in the United States?* This field is required.
Please Select
Please Select
Yes
No
10
Education InformationHighest degree attained or pursuing?*
Please Select
Please Select
High School Diploma/GED
Vocation/Technical Institute
Associate's Degree
Bachelor's Degree
Master's Degree
None
11
Please select all that you have experience as a caregiver?
Bathing/Showering
Grooming
Personal Hygiene
Dressing
Bowel Care
Bladder Care
Feeding
Ambulation
Toileting
Housekeeping
Laundry
Meal Preparation
Shopping
Transportation
Medication Reminding
Other (Specify)
12
What is your availability for work?
Morning
Evening
Overnight
Monday
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Wednesday
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Thusday
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Friday
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Saturday
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Sunday
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Monday
Tueday
Wednesday
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Friday
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Sunday
Morning
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Evening
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Overnight
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Morning
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What is the minimum number of hours you will work in one day ?
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What is the maximum number of hours you will work in one day ?
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Desired start date
Date
Month
Day
Year
16
What languages do you speak?
English
Spanish
European
SouthAsian
Middle Eastern
African
Other
17
Do you have current First Aid Certificate ?
YESNO
18
Do you have current CPR Certificate?
YESNO
19
Have you taken a Food Safety course ?
YESNO
20
To which cities (or county) can you travel for work?
21
What Type of Transportation do you have accessibility?
Private Vehicle (Car/Van/Truck)
Bus
Train
Need a ride
Other (Specify)
22
Do you have a valid Driver’s License?:
YESNO
23
Clients Not Willing/Able to Work With
Dementias/Alzheimer's
Smokers
Mental Retardation
Behavioral Disorders
Elderly (over 65)
Children
Physical Disabilities
Pets
Females
Males
HIV Positive/Aids
Other (Specify)
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Previous Employment details* This field is required.
Company
Supervisor
Phone number
Email
Job title
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Previous Employment start date* This field is required.
Date
Month
Day
Year
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Previous Employment end date* This field is required.
Date
Month
Day
Year
27
Previous Employment Responsibilities* This field is required.
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Previous Employment Reason for leaving* This field is required.
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Reference 1* This field is required.Please use this section to provide a professional or personal references.
Full name
Relationship
Phone number
Email
30
Reference 2* This field is required.Please use this section to provide a professional or personal references.
Full name
Relationship
Phone number
Email
31
EEO Questionnaire -What is your Sex ?* This field is required.EEO Questionnaire - We are an organization that values diversity and encourages women and minorities to apply. For this reason, we invite you to indicate your race/ethnicity below. Submission of this information is strictly voluntary and refusal to provide it will not subject you to any adverse treatment. Responses will remain confidential and will be used only in aggregate to inform our Affirmative Action and Diversity Programs as well as any required government reporting. When reported, data will not identify any specific individuals.
Male
Female
I do not wish to answer
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EEO Questionnaire - What is your race/ethnicity?** This field is required.EEO Questionnaire - We are an organization that values diversity and encourages women and minorities to apply. For this reason, we invite you to indicate your sex below. Submission of this information is strictly voluntary and refusal to provide it will not subject you to any adverse treatment. Responses will remain confidential and will be used only in aggregate to inform our Affirmative Action and Diversity Programs as well as any required government reporting. When reported, data will not identify any specific individuals. What is your race/ethnicity?*
American Indian or Alaska Native
Asian
Black or African American.
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
33
How do you know if you have a disability?* This field is required.A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to: • Alcohol or other substance use disorder (not currently using drugs illegally) • Autoimmune disorders, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS • Blind or low vision • Cancer (past or present) • Cardiovascular or heart disease • Celiac disease • Cerebral palsy • Deaf or serious difficulty hearing • Diabetes • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders • Epilepsy or other seizure disorder • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome • Intellectual or developmental disability • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD • Missing limbs or partially missing limbs • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports • Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS) • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, and other learning disabilities • Partial or complete paralysis (any cause) • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema • Short stature (dwarfism) • Traumatic brain injury Please select one of the boxes below:*
Yes, I have a disability or have had one in the past
No, I do not have a disability and have not had one in the past
I do not want to answer
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Have you ever been convicted of a crime?* This field is required.
YESNO
35
If you have answered YES to any of the questions above, please give further details.
36
How did you hear about us?* This field is required.
Referral
Online Search
Social Media
Job Board
Other
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Certification* This field is required.I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in the rejection of my application. I authorize the 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 the Guardian Angels Home Care Services. I hereby release and discharge any of the above and the Guardian Angels Home Care Services 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 I agree 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 the 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.
I agree
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Select Today's Date* This field is required.
Date
Month
Day
Year
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