Employment Application W2
Email
*
example@example.com
Today's Date
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-
Month
-
Day
Year
Date
Employee Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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-
Month
-
Day
Year
Date
Are you applying to be a Paid Parent Provider? **Please note, parents cannot offer to do RESPITE for their own child**
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Yes
No
Are you related to the client you will be working for?
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Yes
No
If you are related to the client, please specify your relation. (i.e. grandparent, sibling, aunt). If you are not related to the client, type "N/A"
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Do you live with the client?
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Yes
No
Do you already have a client/family that wishes to work with you?
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Yes
No
Please write your client's full name below. If you do not have a client, write N/A.
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Are you 18 years of age or older? (Employees must be at least 18 years old)
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Yes
No
Do you have your own reliable transportation?
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Yes
No
Will you be transporting your client? (Please note that all immediate family members are listed as NON-drivers)
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Yes
No
Maybe
I am applying for the following position(s):
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Respite Care Provider
Habilitation Provider
Attendant Care Provider
All Of The Above
Languages Spoken (ex: English, Spanish, Sign Language)
*
Do you have any experience with individuals with developmental or medical needs?
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Yes
No
No, but I am eager to learn
Yes, but I would need more trainings
Please select if you have THREE or more months of personal and/or professional experience with the following (Check all that apply)
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Working in a Group Home
Working in a Medical Setting
Working in a Special Needs Classroom
Working in a Daycare Center
Babysitting
Providing Habilitation
Providing Respite Care
Providing Attendant Care
Working with an Individual with a Cognitive or Developmental Disability
Working in a Day Program for Individuals with Developmental Disabilities
Working with a Child
Working with an Elderly Individual
Working with an Adult with a Disability
Working with an Individual with Autism
Teaching Children and/or Adults
Working with an Individual with Cerebral Palsy
Working with an Individual with Epilepsy
Working with an Individual with Down Syndrome
None of the Above
Other
If you selected "Other", please explain here.
Please share all relevant experience you have working with individuals with developmental disabilities.
*
Based on state regulations, Branching Out Family Services requires employees to pass background checks through Child and Protective Services, Adult Protective Services, Medicare, Medicaid, and the Arizona Department of Public Safety. I give Branching Out Family Services permission to run a background check for the above background checks and will provide my alias, date of birth, and social security number for this purpose when requested. I am aware that I will also need to obtain a fingerprint clearance card from the Arizona Department of Public Safety. Branching Out Family Services will provide information on how to obtain the fingerprint card.
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Yes
No
What is your availability? (This industry operates 24/7)
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Anytime
After school hours (2pm to 7pm range)
Weekends
Evenings
Mornings
Date Nights
Other
If you selected "Other", please explain here.
How did you hear about this position? Who referred you?
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Summary of Education
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Please check all current certifications you have for the following (Check all that apply)
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CPR
First Aid
Article 9
Level One Fingerprint Clearance Card
Principles of Caregiving 1 (Fundamentals)
Principles of Caregiving 2 (Developmental Disabilities)
Prevention and Support / ABA (Applied Behavior Analysis)
Medication Administration
CNA Training
Seizure Management
Habilitation Trainings
None of the Above
Current or Most Recent Position
*
Current or Most Recent Pay Rate/Salary
*
Please note that for the following three questions regarding your previous employers, YOU MUST INCLUDE ALL INFORMATION FOR EACH EMPLOYER (company name, your position, company/supervisor phone number, and your length of employment).
*
Yes, I understand
No, I do not understand
Other
If you selected "Other", please explain here.
Previous Employer 1
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Rows
Company name
Your position
Supervisor/company phone number
Length of employment
Response
Previous Employer 2
*
Rows
Company name
Your position
Supervisor/company phone number
Length of employment
Response
Previous Employer 3
*
Rows
Company name
Your position
Supervisor/company phone number
Length of employment
Response
Please note that for the following three questions regarding your references, you must include all information for each reference (name, phone number, email address, & their relationship to you). All references provided must be at least 18 years old & NOT RELATED to you in any way.
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Yes, I understand
No, I do not understand
Other
If you selected "Other", please explain here.
Reference 1
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Rows
Reference's name
Phone number
Email
Relationship Type
Response
Reference 2
*
Rows
Reference's name
Phone number
Email
Relationship Type
Response
Reference 3
*
Rows
Reference's name
Phone number
Email
Relationship Type
Response
Emergency Contact (Name, email & phone)
*
I understand and acknowledge that completing this application does not guarantee me employment with Branching Out Family Services and that I will be fully responsible for my safety and professionalism during the interview process. I also understand that Branching Out operates as a W2 agency and must cap working hours at 40 per week.
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Yes
No
Parent Providers: I understand that if my child is a new client with Branching Out, I will also need to complete a "Request for Services" form to begin the new client process. You can locate this on our website under "Get Started".
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Yes
No
N/A
Branching Out uses SMS text messages and informational emails to share company wide information. Please select YES or NO to agree to receive these communications.By becoming a client of Branching Out, you are automatically opted in. You may opt out of text messages or emails at any time by submitting a written request.Branching Out will never sell or share your information. Thank you!
*
Yes, I want to receive SMS texts from Branching Out Family Services
No, I do not want to receive SMS texts. I understand that once I become an employee I will automatically be opted in.
Submit
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