EMPLOYMENT APPLICATION

Youth Support Specialist | Mentor | Direct Support Professional (DSP) | Care Companion

RBC Support Services is hiring compassionate, dependable individuals to provide one-on-one support to children, adolescents, and adults with intellectual, developmental, and/or behavioral health needs. Responsibilities include assisting with daily living skills, promoting independence, providing mentorship, and encouraging community participation in a safe, person-centered environment.
SECTION 1: APPLICANT INFORMATION
Full Legal Name:

First NameMiddle NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address:
Phone Number:

Area CodePhone Number
Referral Source:

Other
SECTION 2: POSITION
Position Applying For:
Date Available to Start

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Desired Hourly Rate:
SECTION 3: AVAILABILITY & PREFERENCES

Please indicate the days and times you are available to work. Check all applicable days and list the specific hours you are available for each day.

Rows	Available (✓)	Available Hours (EXAMPLE: 3PM-8PM)
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY

Available to work weekends?
Preferred Weekly Hours:*
Age Groups You Are Comfortable Working With (select all that apply):
Preferred Work Schedule:

Other
Maximum Travel Distance (commute):
Dates/Times Unavailable:
SECTION 4: TRANSPORTATION & BACKGROUND
Do you have reliable transportation and auto insurance?
Are you a United States Citizen?
If no, are you authorized to work in the U.S.?
Have you ever been convicted of a felony?
If yes, explain:
SECTION 5: EDUCATIONAL HISTORY:
HIGH SCHOOL/GED:
High School Name or GED:
City, State:
Year:
COLLEGE/UNIVERSITY:

(if applicable)
College/University:
Years Attended:
Major:
Degree Received:
Other Education/ Certifications, etc:
SECTION 6: SKILLS & EXPERIENCE
Check all that apply:
SECTION 7: EMPLOYMENT HISTORY
EMPLOYER #1:
Rows Date Started Date Ended

Dates worked for
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Salary/Hourly pay:
Supervisor Name & Contact:
EMPLOYER #2
Rows Date Started Date Ended

Dates worked for
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Salary/Hourly rate:
Supervisor Name & Contact:
SECTION 8: REFERENCES
Reference #1 (Name & Phone Number):
Reference #2 (Name & Phone Number):
Reference #3 (Name & Phone Number):
Hobbies, interests, or other information:
Name:Date:
UPLOAD RESUME:
UPLOAD RESUME: If you have trouble uploading documents, email document(s) to hr@rbcsupportservices.org

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SECTION 1: APPLICANT INFORMATION