Upload 2 Forms of ID:
Caregiver Application
Joyce's Caring Touch Home Health LLC 2266 N Prospect Ave, STE 210 Milwaukee, WI 53202 Phone:414-841-5853 Fax: 414-921-5589 Email: contactjct@jcthomecare.com
By completing this application, you acknowledge ALL caregivers require background checks and they must be performed at the time of hire and at least every 4 years thereafter, to stay in compliance with Department of Health Services (DHS).
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
SSN Number
*
Enter Social Security Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Position you are applying for:
PCW
Under 20 hrs per week
More than 20 hrs per week
Are you authorized to work In The United States?
*
Yes
No
Background Check Disclosure
By submitting this application, you acknowledge that a background check may be required as part of the hiring process. This section explains that any offer or continued consideration may depend on the results of that screening and any information you provide.
I consent to the background check disclosure
*
Yes
No
I understand and agree to the background check disclosure above.
*
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Employment Desired:
Date You Can Start
*
-
Month
-
Day
Year
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Salary Desired
Days and Times Available (check all that apply):
Mon - Fri (Weekdays ONLY)
Sun - Sat (Weekdays and Weekends)
Mornings (7 AM - 11 AM)
Afternoons (12 PM - 4PM)
Evenings ( 5PM - 9PM)
On Call
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List caregiving experience:
Important Note: This is much more than a job to us. We are looking for caregivers that understand the significance of being welcomed into a family to provide care to their loved ones.
Do You Have Reliable Transportation
*
Yes
No
Skills/Qualifications:
CPR/First Aid Certified?
Please Select
Yes
No
Willing to Get Certified
Name of CPR/FA instructor:
Phone number for CPR/FA instructor:
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Education:
Highest Level of Education:
*
Please Select
High School
College
Graduate School
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
Trade School/Other
Name of Trade/Technical/Other School Attended
List of other professional training:
i.e. STARS, NCS, Doula training, conference workshops, etc.
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Job History
Current Employer Name
i.e. Name of Family
Current Employer Position
Your job title
Current Employer Salary
Current Employer Start Date
-
Month
-
Day
Year
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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 Employer
i.e. Name of Family
Previous Employer Position
Your job title
Previous Employer Salary
Previous Employer Start Date
-
Month
-
Day
Year
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Previous Employer End Date
-
Month
-
Day
Year
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Previous Employer Duties
Please include an in-depth job description
Previous Employer Reason for Leaving?
Previous Employer May We Contact?
Yes
No
If 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
1st Reference
Name of Reference
1st Reference Relationship
1st Reference Phone
Please enter a valid phone number.
Format: (000) 000-0000.
2nd Reference
Name of Reference
2nd Reference Relationship
2nd Reference Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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Please Upload a copy of your State Issued Photo ID and birth certificate/or Social Security Card.
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Upload Your Resume(optional):
Acknowledgement
I have uploaded 2 forms of ID and a resume(optional). Without 2 forms of ID, I understand that my application may not be considered.
Signature
Date
*
-
Month
-
Day
Year
Date
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