Employment Application
Peer support coach
Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Position Applying For
Peer support coach
Kitchen Staff
Sanitation
House Manager
Employment Type
Full-time
Part-time
Contractor
Availability Days/Time
Are you legally authorized to work in the United States
yes
no
Are you willing to complete CBI finger-print based background check? please note that having a criminal record does not automatically disqualify candidates
yes
no
Do you understand this role involves working with adults and children?
yes
no
Please describe any lived experience(Peer Requirement) experience ie: housing instability, justice involvement, mental heath, life transitions
Highest level of completed education
do you have peer support certification if so please upload
yes
no
other certifications (I.E: CPR, First Aid etc)
Certificate
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Resume
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Do you have 2 forms of Identification
yes
no
Check Each Box that you understand
I understand this is a non-clinical peer support role
I understand that I am responsible for all CBI background check Fee $65.00 if hired it will be refunded in your first pay check
I agree to maintain confidentiality and professional boundaries
I agree to follow ethical peer support standards
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
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