Support Worker Application
Phoenix Healthcare - Home and Community
1. Name
*
First Name
Last Name
2. Email
*
example@example.com
3. Phone Number
*
-
Area Code
Phone Number
4. Address
*
Street Address
Street Address Line 2
City
Province
Postal code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5. Resume
*
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6. Date Available
*
-
Month
-
Day
Year
Date
7. Work location
Suburbs
8. References (Name, Company, and Contact Info)
*
Back
Next
9. Gender (please note that this information is not used for selection purposes)
*
Female
Male
Other
10. Ethnicity (please note that this information is not used for selection purposes)
*
Please Select
European or Pākehā
Māori
Pasifika
Asian
Middle Eastern
Latin American
African
Other
10a. Please Specify
11. Date of Birth
*
Date/Month/Year
12. Please indicate your eligibility to work in New Zealand
*
Please Select
NZ/AU Citizen
NZ Permanent Resident
NZ Resident
Valid Work Visa
Student Visa
No Work Visa
Other
12a. Please specify
13. Are you currently legally allowed to drive in New Zealand?
*
Yes
No
14. Please indicate which licence you currently hold
*
Full
Restricted
Learner
International
15. Do you have any cases pending that could affect your licence?
*
Yes
No
15a. If yes, please provide details:
16. Do you own your own reliable vehicle?
*
Yes
No
17. Do you have access to a Smart Phone (with data) in order to use our rostering app?
*
Yes
No
18. Having a valid and current First Aid certificate is important in this role to help ensure the safety and well-being of those you support. Your ability to provide immediate care in an emergency can make a significant difference. Do you currently hold a valid First Aid Certificate?
*
Yes
No
18a. If yes, please provide the date you completed your most recent First Aid Training
19. What days and hours would you be available to work?
*
20. Are you able to work BOTH a Saturday AND Sunday?
*
Yes
No
21. Do you have working experience as a support worker? If so for how long?
*
22. Please list any qualifications relevant to this position, along with the Institution/ Qualification provider:
*
23. Next of Kin
*
First Name
Last Name
24. Relationship to the person
*
Spouse, Parent, Child, Sibling etc
25. Email
*
example@example.com
26. Phone Number
*
-
Area Code
Phone Number
Back
Next
27. As a Community Support Worker, you may be providing support in clients' homes where pets are present. To help us ensure a comfortable and safe work environment for you, please let us know if you have any pet allergies or if you feel uneasy around certain types of pets. Please note that while we cannot guarantee a pet-free environment, we will do our best to consider your preferences when scheduling your hours. Do you have any pet allergies?
*
Yes
No
28. Are there any pets you feel uncomfortable being around?
*
Yes
No
28a. If yes to either question, please provide details:
29. Have you previously been employed by Phoenix Healthcare Group? If yes, could you please provide the details of your role and the approximate dates of your employment?
*
30. Are you currently engaged in any form of secondary employment?
*
Yes
No
30a. If yes, please provide details:
31. As a Community Support Worker, you may be required to: • Prepare meals that meet a variety of dietary needs (e.g. vegetarian, pescatarian, or other specific requirements). • Handle and cook different types of food, including pork, beef, chicken, and fish.
*
Please provide • Details of your experience preparing meals for clients with diverse dietary preferences. • Any professional training or certifications in nutrition or meal planning. We respect and support the dietary preferences, cultural practices, and religious beliefs of our staff. • If you have any dietary restrictions or cultural considerations that may affect your ability to handle or prepare certain foods, please let us know so that appropriate accommodations can be made.
32. Given the nature of the tasks associated with prospective employment, do you suffer from any injury, ailment, condition, or disability which may adversely limit or prevent you from carrying out the functions of this position?
*
Yes
No
32a. If yes, please provide details
33. Are you currently receiving medical treatment or under medication, or suffer a condition which we should be aware of so that we can provide appropriate assistance should the need arise?
*
Yes
No
34a. If yes, please provide details:
35. If required, do you agree to attend a Registered Health Professional nominated by the employer to undertake a consultation, examination or tests as may be appropriately required?
*
Yes
No
36. Due to the risk of working in the community which can provide a high risk of illness through the transmission of infectious diseases, can you confirm if you have had a Flu Shot (Influzenza Group A) & COVID-19 (including boosters) vaccinations?
*
Yes
No
37. Do you have any criminal convictions, or currently being investigated for any criminal offence in any country?
*
Yes
No
37a. If yes, please provide details:
38. Do you consent to inquires being made as to the accuracy of information in this application form and in your curriculum vitae e.g., drivers licence check, qualifications check?
*
Yes
No
39. Do you consent to a police security check?
*
Yes
No
40. To ensure your safety and well-being, we ask that you provide the name and contact details of a person we can reach out to in case of an emergency during your employment. This individual can be anyone you trust, such as a family member, friend, or another person of your choosing.
*
Name, Relationship to You, Primary Phone Number, Alternate Phone Number (if available), Email address
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