ASCL Caregiver Employment Application
Organization: ASCL - Accessible Supportive Care & Living
Position Applying For: Caregiver / In-Home Care Provider
Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. Applicant Information
Full Name:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you legally authorized to work in the U.S.?
Yes
No
Do you have reliable transportation?
Yes
No
Availability:
Full-Time
Part-Time
Weekends
Nights / Overnight Care
2. Caregiver Experience
Do you have previous caregiving or home health experience?
Yes
No
If yes, please explain:
Experience with:
Seniors
Veterans
Individuals with Disabilities
Individuals experiencing homelessness
Dementia / Alzheimer's care
Personal care assistance
3. Certifications & Training
Certifications:
CPR Certified
First Aid Certified
CNA
Home Health Aide
Medication Training
Other:
Certification Number:
4. Work History
Most Recent Employer:
Company Name:
Back
Next
Position:
Dates Employed:
Reason for Leaving:
Previous Employer:
Company Name:
Position:
Dates Employed:
Reason for Leaving:
5. Background Information
Are you willing to undergo a background check?
Yes
No
Have you ever been convicted of a crime that would affect your ability to work as a caregiver?
Yes
No
If yes, explain:
6. References
Reference #1 Name:
Phone:
Format: (000) 000-0000.
Relationship:
Reference #2 Name:
Phone:
Format: (000) 000-0000.
Relationship:
7. Why Do You Want to Work With ASCL?
8. Applicant Certification
I certify that the information provided is true and complete.
Applicant Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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