Availability Form
Applicants Name:
*
First Name
Last Name
Gender:
*
Male
Female
1. Are you willing to work with female patients?
*
Yes
No
2. Are you willing to work with male patients?
*
Yes
No
3.What is your primary Language?
*
English
Spanish
French
Russian
German
4. Click any other languages you speak.
English
Spanish
French
Russian
German
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5. Do you have a car?
*
Yes
No
6. Are you interested in driving clients?
*
Yes
No
7. Are you willing to work with a client who smokes?
*
Yes
No
8. Are you willing to work in a home that has pets?
*
Yes
No
9. Please mark off any pets you allergic to or not willing to work with.
*
Cats
Dogs
Birds
Other
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11. What areas are you willing to travel, please choose 4 or more locations below:
*
Atkinson
Bald Head Island
Bayshore
Belville
Boiling Spring lakes
Burgaw
Calabash
Carolina Beach
Carolina Shores
Castle Hayne
Caswell Beach
Hampstead
Hightsville
Holden Beach
Kings Grant
Leland
Long Creek
Maple Hill
Murrayville
Myrtle Grove
Navassa
Northwest
Oak Island
Ocean Isle Beach
Ogden
Porters Neck
Rocky Point
Saint Helena
Saint James
Sandy Creek
Shallotte
Silver Lake
Southport
Sunset Beach
Topsail Beach
Varnamtown
Watha
Wilmington
Wrightsboro
12. Please fill in the chart below with the time you are available each day. If you are not available, leave the box blank for that day.
*
Rows
Start (AM/PM)
End (AM/PM)
Sat.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Sun.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Mon.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Tue.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Wed.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Thurs.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Wed.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Fri.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
13. I am willing to work Live-in or overnight cases.
*
Rows
Yes
No
Live-In
Overnight
Live-in cases are defined as 24-hour shifts (13hours paid). If choosing "Live-in" please select the following:
*
Please Select
I am willing to work a 7-day live-in.
I am willing to work a 3-4 day live-in.
Not interested.
Please note 7 days live in cases are limited
Signature
*
Date
*
/
Month
/
Day
Year
Date
Submit
Submit
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