Steadfast Home Healthcare Application for Caregivers

Steadfast Home Healthcare Application for Caregivers
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Employer
Years of Experience in Healthcare
Social Security Number
Highest Level of Education
Photo ID upload

Cancelof
Date Available to Begin Working

MonthDayYear
Date
Are you a citizen of the United States?
Are you at least 18 years of age?
Are you able to meet the physical and mental demands required to perform specific tasks for an elderly or disabled client?
Will you maintain confidentiality?
Are you emotionally mature and dependable?
Are you able to handle emergency situations?
Are you not the participants spouse?
Have you lived in Missouri for the last 5 years?
If no, please list the state(s) you have lived in below.
Do you smoke?
How did you learn about this position?
Is there any reason you would not be able to perform and household duties?
If yes, please explain why.
If you are hired for the position of Personal Care Attendant (PCA), a background screening via the Family Care Safety Registry (FCSR) must be conducted prior to your first day of employment. Please read the following questions carefully and respond truthfully and fully.
Have you been charged with an offense other than a minor traffic violation?
Disclose all criminal convictions, findings of guilt, and pleas of nolo contendere or provide a statement that there is no record of such background. Failure to disclose any criminal information is a violation of the law. If this does not apply, please use N/A. If Yes, Give Offense and Date for Each Crime:
I give STEADFAST HOME HEALTHCARE LLC consent to conduct a pre-employment criminal record check.
I authorize STEADFAST HOME HEALTHCARE LLC to conduct a closed record check pursuant to Section 610.120, RSMo.
Have you ever used any aliases and social security numbers other than the name and social security number you used on this application?
If Yes, please disclose all aliases and social security numbers that you have used.
Are you registered with the Family Care Safety Registry (FCSR)?
Have you ever applied for a Good Cause Waiver?
If Yes, when?
Do you have a Skilled License?
Do you have a valid Drivers License?
Do you have transportation?
Have you ever worked with persons with physical/cognitive disabilities?
If Yes, please explain.
Preferences and Availability
Do you prefer males, females or either?
What days are you available?
Please check the following duties that you are willing and able to perform on a daily basis.
Employment History
Upload Resume

Cancelof
Company Name
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor
Your Position
Date Started Job

MonthDayYear
Date
Last Day of Employment

MonthDayYear
Date
May we contact this employer?
What were your duties?
What was your reason for leaving?
Are you eligible for rehire?
I certify that all of the information contained in the application is true and complete and I authorize verification of any or all information presented above.
Signature
Todays date of signing

MonthDayYear
Date
STEADFAST HOME HEALTHCARE LLC is an equal oppurtunity employer. In accordance with the Civil Rights Act of 1964, our agency does not discriminate in employment due to race, creed, religion, age, national origin or disability.
Should be Empty:

Steadfast Home Healthcare Application for Caregivers

Preferences and Availability

Employment History