• Job Application for Employment

    Emeritus Home Care

  • Emeritus Home Care Does not discriminate in hiring or employment based on race, color, religion, national origin, age, sex, disability, sexual orientation, Vietnam era
    military service, or any other basis on which discrimination is prohibited by federal, state, or local laws. No questions on this application are intended to secure information to be used for such discrimination.


    Each question should be answered fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper if
    you do not have enough room on this application. PLEASE PRINT, except fors ignature on back of application. In reading and answering the following questions, please be aware that none of the questions are intended to imply illegal preference or discrimination based upon non-job-related information.

  • Personal Information

  • Format: (000) 000-0000.
  • Date of Birth:*
     - -
  • Are you 18+?*
  • Primary Language Spoken*
  • English Proficiency*

  • Employment Questions

  • Date Available to Start:*
     - -
  • Are you currently employed?*
  • Have you ever applied to this company before?*
  • Are you legally authorized to work in the United States?*
  • Will you now or in the future require employer sponsorship for employment authorization (for example, H-1B visa, work permit renewal, etc.)?*
  • What is your current work authorization status?*
  • If applicable, please indicate the expiration date of your current work authorization:
     - -

  • Education

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  • Employment History

    Please list at least a minimum of 5 years of work history.
  • Rows

  • References

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  • I hereby authorize Emeritus Home Care to contact my current/former employers which I have provided. I give my permission to release any information deemed necessary for the purpose of evaluating me for possible employment.

  • Date*
     - -
  • Have you ever been convicted of any law (except a minor traffic violation)?*
  • Are you now or do you expect to be engaged in any other business or employment?*

  • Acceptance of this application affords no assurance of eventual employment. If employed, you will be required to verify your ability to legally accept employment
    in the United States. For certain jobs, background investigations, to include contacting former employers, may be required. This application does not constitute a contract of employment. Employment and compensation can be terminated with or without notice, and with or without cause, at any time.


    I have read the foregoing instructions and questions and to the best of my knowledge my answers are true and correct. I have not knowingly misrepresented or withheld any fact or circumstance that would, if disclosed, affect my application unfavorably. I understand that misrepresentation of any of the above may be caused
    for termination.

  • Date*
     - -

  • Employment Availability

  • Do you have your own motor vehicle?*
  • Do you have any allergies that would affect your work?*
  • Do you have a problem working with a client who smokes?*
  • Locations (counties) willing to work:*
  • Rows

  • Photography, Video, and Media Release Consent Agreement

    Emeritus Home Care

  • Emeritus Home Care ("the Company") occasionally captures photographs, audio recordings, video recordings, or written testimonials ("Media") of clients, employees, contractors, and other individuals for lawful business purposes, including but not limited to marketing, advertising, educational, training, public relations, and internal communications.

    This Consent Agreement provides authorization for Emeritus Home Care to capture and use such Media.

  • Grant of Rights

  • I, the undersigned, hereby grant Emeritus Home Care, its legal representatives, successors, assigns, licensees, partners, and affiliates:

    • The full, irrevocable, worldwide, royalty-free right to capture, reproduce, publish, distribute, edit, adapt, display, exhibit, broadcast, and otherwise use my likeness, voice, image, photograph, video, audio, interview, testimonial, or any other representation (collectively, "Media") in any format, now known or developed in the future, for lawful business purposes.
    • The right to use my name, biographical information, and statements associated with the Media, as appropriate.
    • The right to use, reuse, modify, and repurpose the Media, in whole or in part, without limitation as to time, format, or location.

  • Scope of Use

  • This authorization includes, but is not limited to:

    • Marketing materials (print, digital, online, television, social media, websites, flyers, brochures, advertisements, email campaigns, newsletters, press releases, etc.)
    • Internal training and education
    • Public relations, promotional campaigns, and business development activities
    • Third-party publications or collaborative projects related to the Company's business activities

  • Confidentiality and Privacy

    • Emeritus Home Care will not disclose any protected health information (PHI) or personally identifiable information (PII) that violates HIPAA, applicable state privacy laws, or company confidentiality policies.
    • This release does not authorize disclosure of medical or personal details unless specifically and separately authorized.

  • Voluntary Participation

    • I understand that my participation is entirely voluntary.
    • My decision to grant or withhold consent will not affect the care, services, employment status, or relationship I have with Emeritus Home Care.

  • Waiver of Rights and Release of Claims

    • I waive any right to inspect or approve the Media or the specific uses of the Media.
    • I acknowledge that I will not receive financial compensation for the use of the Media.
    • I release, discharge, and hold harmless Emeritus Home Care, its agents, employees, contractors, successors, assigns, affiliates, partners, and any third parties authorized to use the Media, from any claims, demands, or causes of action arising out of the use, reproduction, distribution, or display of the Media, including without limitation any claims for defamation, invasion of privacy, rights of publicity, or infringement of moral rights.

  • Duration of Consent

  • This consent is perpetual, valid indefinitely, and may not be revoked except in writing and with the written agreement of Emeritus Home Care. Any revocation will not apply to Media already captured or previously published.

  • Authorization and Acknowledgment*
  • Date
     / /

  • Background Check Authorization Form

    All information will be kept strictly confidential
  • Date of Birth:*
     - -
  • Race:*
  • Sex:*
  • Is Mailing Address same as Permanent Address?*
  • Date of Expiration
     - -
  • Is there anything in your lifestyle or background that would call into question your ability?*

  • I hereby authorize Emeritus Home Care To make an independent investigation of my background and criminal or police records. I release Emeritus Home Care and any person or entity which provides information pursuant to this authorization, from all liabilities, claims, or lawsuits regarding the information obtained from all the above sources. The information contained in this application is correct to the best of my knowledge. I understand that any omission of material fact on this application may be grounds for rejection of this application.

  • Date*
     - -

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Office Team Pre-Screening Questionnaire

  • How many years of administrative or office experience do you have?*
  • How many years of human resources (HR) or employee coordination experience do you have?*
  • Have you ever managed employee schedules or coordinated shift coverage?*
  • Have you previously worked in a healthcare or home care office setting?*
  • Are you proficient with Microsoft Office (Word, Excel) or Google Workspace (Docs, Sheets, Gmail)?*
  • How confident and comfortable are you managing phone calls, scheduling, and data entry?*
  • Are you comfortable working in a fast-paced environment where priorities can change very quickly?*
  • Should be Empty: