More Healing Care LLC – Employment Application

Non-Medical Homemaker position with More Healing Care LLC.* This field is required. This position is limited to non-medical services only. If this does not align with your expectations, please do not continue this application. Please confirm that you understand this position involves non-medical in-home support services only and does not include medical, clinical, or skilled nursing care.

Yes

Full Legal Name* This field is required.Enter your full legal name as it appears on your government-issued photo identification. This information will be used for employment eligibility verification, background screening, and personnel records.

Prefix

First Legal Name

Legal Last Name

Age Eligibility Confirmation* This field is required.Are you at least 18 years of age?

Yes

Email Address* This field is required. Provide a valid email address where you can receive employment-related communications, including application status updates, interview scheduling, and onboarding instructions.

Email Address

Confirm Email

Primary Phone Number* This field is required.Enter a valid phone number where you can be reached regarding your application. This number may be used for interview scheduling and employment-related communication.

Please enter a valid U.S. phone number, including area code.

Residential Address* This field is required.Please enter your current residential address. This information is used for employment records, background screening, and service assignment purposes.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Position Applied For* This field is required.Select the position for which you are applying with More Healing Care LLC.

Position Applying For

Highest Level of Education This information is collected for personnel recordkeeping purposes only. Educational attainment is not a condition of employment for non-medical caregiver positions and will not be used as the sole basis for hiring decisions.

Educational Institution Attended Please provide the name of the educational institution you attended. This information is collected for employment records and qualification review purposes only.

Year of Graduation or Last Attendance If applicable, enter the year you completed or last attended the educational program listed above. This information is collected for employment records and qualification review only.

Employment Preference* This field is required.

Full-Time

Part-Time

PRN / As Needed

Flexible / Open Availability

Days Available to Work* This field is required. Availability information is used for scheduling purposes only and does not guarantee hours, shifts, or assignments.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Weekend Availability

Holiday Availability

Time of Day Available* This field is required.

Morning

Afternoon

Evening

Overnight

Additional Scheduling or Availability InformationPlease use this space to clarify scheduling limitations, shift preferences, transportation considerations, or any other availability-related details relevant to employment.

Work Experience Summary (Brief Description)* This field is required.Brief description of prior non-medical caregiving or support experience (Do not include medical diagnoses or protected health information)

Example: Provided companionship, meal preparation, light housekeeping, and assistance with daily activities for older adults and individuals with disabilities. Approximately 2 years of experience in non-medical home care and support roles.

Caregiver Experience Level (Years in Home Care or Related Support Roles)* This field is required. Enter the total number of full years of experience you have providing paid non-medical home care, personal assistance, homemaker services, companionship, or similar support roles. Include both agency-based and private caregiving experience. Do not include unpaid or informal experience unless it is relevant.

e.g., 1, 2, 5

Upload Resume (Optional) If available, please upload a current resume outlining your work history and relevant experience. Submission of a resume is optional and does not replace completion of all required sections of this application.

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Select files to upload

Max. file size: 10.0MB

Accepted formats: PDF, DOC, or DOCX (maximum 10 MB).

Reference NamePlease provide the full name of a professional or personal reference who can speak to your work history, reliability, or character. Do not list family members.

Please list a professional or personal reference who can speak to your work or character.

Reference RelationshipPlease indicate how you know this person (e.g., supervisor, coworker, client, teacher). Family members should not be listed as references.

Relationship to you

Reference Contact InformationPlease provide at least one way to contact this reference (phone number and/or email address).

At least one method of contact is required (phone or email).

NON-MEDICAL TASKS YOU ARE WILLING TO PERFORM Selection does not guarantee assignment. Services must align with agency policy and client care plans.

Personal Care Assistance (bathing, grooming, dressing)

Activities of Daily Living (ADLs)

Mobility Assistance

Transfer Assistance

Companionship

Emotional Support

Dementia / Alzheimer’s Support

Medication Reminders (non-medical only)

Meal Preparation

Feeding Assistance

Light Housekeeping

Home Safety Observation

Reporting Changes in Client Condition

Infection Control Practices

Personal Hygiene Support

Client Dignity & Respect

Privacy & Confidentiality

Following Care Plan Instructions

Documentation & Shift Notes

Safety Awareness & Fall Prevention

Transportation Assistance

Cultural Sensitivity

Independent Work in Client Homes

Other (please specify)

Professional Skills & Strengths* This field is required. Purpose: HR evaluation (separate from tasks) Checkbox list:

Communication Skills

Interpersonal Skills

Compassion and Empathy

Teamwork and Collaboration

Problem-Solving Skills

Time Management

Reliability and Punctuality

Attention to Detail

Client Support and Personal Care Assistance (non-medical)

Household Support (cleaning, meal preparation, errands)

Documentation and Record Keeping

Technology and Mobile App Use (EVV, scheduling, communication tools)

Conflict Resolution

Leadership or Supervisory Experience

Other (please specify)

Have you received Supplemental Nutrition Assistance Program (SNAP) benefits within the past six (6) months?* This field is required.This question is used solely for potential federal tax credit eligibility and does not impact employment decisions.

Yes

Have you received Temporary Assistance for Needy Families (TANF) benefits within the past two (2) years?* This field is required.This question is used solely for potential federal Work Opportunity Tax Credit (WOTC) eligibility and does not impact employment decisions.

Yes

Have you been unemployed for twenty-seven (27) consecutive weeks or longer within the past twelve (12) months?* This field is required.This question is used solely for potential federal Work Opportunity Tax Credit (WOTC) eligibility and does not impact employment decisions.

Yes

Are you a veteran of the United States Armed Forces?* This field is required.This question is used solely for potential federal Work Opportunity Tax Credit (WOTC) eligibility and does not impact employment decisions.

Yes

Were you referred to this position by a State Workforce Agency or American Job Center?* This field is required.This question is used solely for potential federal Work Opportunity Tax Credit (WOTC) eligibility and does not impact employment decisions.

Yes

Upload Completed IRS Form 8850 – Pre-Screening Notice and Certification RequestRequired only if you answered “Yes” to any WOTC screening question above. Please upload a completed and signed IRS Form 8850.

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Max. file size: 10.0MB

Upload Completed ETA Form 9061 – Individual Characteristics FormRequired only if you answered “Yes” to any WOTC screening question above. Please upload a completed and signed ETA Form 9061.

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Max. file size: 10.0MB

I certify that the information provided for Work Opportunity Tax Credit (WOTC) processing is true, complete, and accurate to the best of my knowledge.

Electronic Signature – WOTC CertificationBy signing below, you certify that the information provided is true and accurate for Work Opportunity Tax Credit (WOTC) eligibility determination.

Date of CertificationEnter the date you are signing this certification.

MM/DD/YYYY

Acknowledgment of Non-Medical Services and Employment Conditions By continuing this application for employment, I understand and acknowledge that More Healing Care LLC provides non-medical in-home support services only and does not provide medical, clinical, or skilled nursing care.

I further acknowledge that, if hired, I may be assigned to provide services within designated service areas based on agency operational needs, client care plans, and my stated availability.
&#13;&#10;&#13;&#10; I understand that service assignments, schedules, hours, and locations are not guaranteed and may change based on agency operations, client needs, and program requirements.
&#13;&#10;&#13;&#10;I understand that services may be provided across designated service areas, including but not limited to Cook, DuPage, Will, Kane, Lake, DeKalb, Grundy, Kendall, and McHenry Counties, based on client needs, availability, and agency operations.
&#13;&#10;&#13;&#10;I acknowledge that no services may be rendered until all required employment documentation, acknowledgments, background clearances, credentialing, and training requirements have been fully completed, reviewed, and approved in accordance with agency policy and applicable federal, state, and program regulations.
&#13;&#10;&#13;&#10;I further acknowledge that submission of this application does not guarantee employment and that any offer of employment is contingent upon successful completion of all required hiring, screening, training, credentialing, and compliance requirements established by More Healing Care LLC and applicable regulations.

Read-only acknowledgment

I Acknowledge * This field is required.The Acknowledgment of Non-Medical Services and Employment Conditions I acknowledge that I have read and understand the above employment conditions and that submission of this application does not guarantee employment with More Healing Care LLC.

Yes

Acknowledgment of Non-Medical Services, Employment Conditions, and Job Requirements By continuing this application for employment, I acknowledge and understand that More Healing Care LLC provides non-medical in-home support services only and does not provide medical, clinical, or skilled nursing care.

I further acknowledge that, if hired, I may be assigned to provide services within designated service areas based on agency needs, client care plans, and my stated availability. 
&#13;&#10;&#13;&#10;I understand that service assignments, schedules, hours, and locations are not guaranteed and may change based on operational requirements.
&#13;&#10;&#13;&#10;I understand that no services may be rendered until all required documentation, acknowledgments, background clearances, training, and onboarding requirements have been completed, reviewed, and approved in accordance with agency policy and applicable regulations.
&#13;&#10;&#13;&#10;I acknowledge that submission of this application does not guarantee employment and that any offer of employment is contingent upon meeting all hiring, screening, training, and compliance requirements established by More Healing Care LLC.
&#13;&#10;&#13;&#10;If hired, I understand that I will be required to review and sign all mandatory acknowledgments, policies, and compliance documents prior to performing any non-medical home care services on behalf of More Healing Care LLC.
&#13;&#10;&#13;&#10;I further acknowledge and understand that this position may require physical activity typical of non-medical in-home support services, including but not limited to standing, walking, assisting with errands, light housekeeping tasks, meal preparation, and other non-medical duties as assigned. Essential job functions may include providing non-medical in-home support services such as personal care assistance, companionship, light housekeeping, meal preparation, and related tasks in accordance with client care plans and agency policy.

Read-only acknowledgment:

I Acknowledge * This field is required.The Acknowledgment of Non-Medical Services, Employment Conditions, and Job Requirements I acknowledge that I have read and understand the above employment conditions and that submission of this application does not guarantee employment with More Healing Care LLC.

Yes

Electronic Signature Acknowledgment* This field is required.By typing your full legal name below, you are providing your electronic signature and certifying that all information provided in this application is true, complete, and accurate to the best of your knowledge. You acknowledge that this electronic signature is legally binding and equivalent to a handwritten signature under applicable federal and Illinois law. You understand that any false, misleading, or omitted information may result in disqualification from employment consideration or termination if hired.

Signature Date* This field is required.Please enter the date on which you are electronically signing this employment application. This date confirms when your electronic signature was executed and acknowledged. * The signature date will be maintained as part of your employment record and used for verification and compliance purposes.

Signature Date

More Healing Care LLC – Employment Application