Trinity Home Care and Resource Application Form
Please fill out all questions below. After submitting, we will reach out to you shortly. All employees of Trinity Home Care and Resource MUST be 18 years or older and be able to pass a criminal history background check.
Name
*
First Name
Last Name
Position Applying For:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Are you legally authorized to work in the United States?
*
Yes
No
Have you ever been convicted of a crime other than a minor traffic violation?
*
Yes
No
Do you have a current Driver's License?
*
Yes
No
Are you applying for:
*
Full Time
Part Time
Temporary
Any
Are you at least 18 years of age?
*
Yes
No
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Employment History
Begin with most recent employment
Job Title
*
Start Date
*
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Company Name
*
City/State
*
Duties
*
Reason for Leaving
*
Supervisor's Name
*
Phone Number
*
Please enter a valid phone number.
May we contact?
*
Yes
No
Ending Pay
*
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Next
Employment History
Continue to next page of not applicable
Job Title
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Company Name
City/State
Duties
Reason for Leaving
Supervisor's Name
Phone Number
Please enter a valid phone number.
May we contact?
Yes
No
Ending Pay
Back
Next
Employment History
Continue to next page of not applicable
Job Title
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Company Name
City/State
Duties
Reason for Leaving
Supervisor's Name
Phone Number
Please enter a valid phone number.
May we contact?
Yes
No
Ending Pay
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Education
Highest Level Completed
*
Where:
*
Year
*
Have you attended a caregiver course, CNA, or other formalized training program for this type of work?
*
Yes
No
If so, what course?
Where Taken?
Year
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Professional Certificates/Licenses
CPR, CNA, Med Tech, EMT, etc.
Type
Expiration Date
-
Month
-
Day
Year
Date
Type
Expiration Date
-
Month
-
Day
Year
Date
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Caregiver Experience
Do you have professional caregiver experience?
Yes
No
Name of Employer
Dates
Name of Employer
Dates
Do you speak any languages other than English?
*
Yes
No
If yes, please list:
Will you work with a client where most of the work is housekeeping?
*
Yes
No
Will you work with a client who is incontinent?
*
Yes
No
Will you work with children?
*
Yes
No
Mark for following you ARE comfortable working around
*
Dogs
Cats
Dust
Smoke
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Experience Checklist
Please mark the following tasks and conditions you have worked with or have previous experience with
Skills
*
Toileting
Giving Bed Baths
Changing Attends
Walking Assist
Pivot Transfer
Transfer Board
Lifting (light)
Lifting (full)
Emptying Catheter Bag
Light Housekeeping
Gait Belt
Shower Assist
Hoyer Lift
Meal Prep
Peri-Care
Bowel Care
G-Tube
No experience with skills listed
Diagnoses/Conditions
*
Alzheimer's/Dementia
CHF
Quadriplegia
ADHD
Schizophrenia
Mental Illness
Bi-Polar
Amputation
Diabetes
Parkinson's
COPD
TBI
Developmental Delay
Client Receiving Oxygen
Failure to Thrive
Stroke
ALS
Huntington's
Autism
Depression
Hospice
Cancer
Blindness
No experience with diagnoses listed
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Availability/Schedule Preferences
What shifts will you work?
*
Days
Evenings
Nights
Weekends
Holidays
2-3 Hours
4-6 Hours
8 Hours
12 Hours
24 Hours
What days will you work?
*
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
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References
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Type
*
Business
Personal
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Type
Business
Personal
Why should we consider you to work with our clients?
*
Submit
Should be Empty: