Devine Care Solutions Caregiver Employment Application

Devine Care Solutions Caregiver Employment Application
Thank you for your interest in joining Devine Care Solutions. Please complete this application fully and accurately. This application helps us review your qualifications, availability, work history, and ability to provide safe, dependable, non-medical support services to individuals receiving care. Completion of this application does not guarantee employment.
First Name Middle NameLast NameSuffix
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Have you lived at your current address for at least 2 years?
Previous Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Position & Availability
Position you would like to apply for?

Other
Desired Start Date

MonthDayYear
Date
Are you currently employed?
If "Yes" Please list current employer.
Available on Monday?
Monday availability
Available on Tuesday?
Tuesday availability
Available on Wednesday?
Wednesday availability
Available on Thursday?
Thursday availability
Available on Friday?
Friday availability
Available on Saturday?
Saturday availability
Available on Sunday?
Sunday availability
Current Availability
Overnight Availability
How many hours per week are you seeking?
Are you willing to work weekends?
Are you willing to travel to client homes and community location?
Section 3: Work Authorization and Employment Eligibility
Are you legally authorized to work in the United States?
Will you be able to provide documentation verifying your identity and employment authorization if hired?
Are you at least 18 years old?
Section 4: Driver and Transportation Information
Do you have a valid driver's license?
Driver License or Identification Number
State Driver License or Identification was issued
Driver License Expiration Date

MonthDayYear
Date
Do you have reliable transportation?
Vehicle Year: Make: Model
Do you currently have auto insurance?
Auto Insurance Company & Policy Number
Are you willing to provide proof of Driver's license, Registration, and Auto insurance if hired?
Section 5: Experience & Qualifications
Do you have caregiving, direct support, home care, or healthcare experience?
Please describe your caregiving or related experience?
Have you ever worked with individuals with developmental disabilities?
Have you completed CPR/First Aid training?
Do you have any APD, Medicaid Waiver, direct care, or caregiver-related trainings/certifications?
Do you currently have a TRAIN Florida Account?
Are you comfortable assisting with personal care tasks such as bathing, dressing, grooming, meal preparation, light housekeeping, and safety supervison?
Are you comfortable completing daily service notes/documentation after each shift?
Section 6: Language skills
What languages do you speak?
What languages do you read/write?
Section 7: Employment history
Most recent employer
Employer name
Position held
Supervisor name
Supervisor phone number
Please enter a valid phone number.Format: (000) 000-0000.
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Reason for leaving
May we contact this employer
Previous employer 1
Employer name
Position held
Supervisor name
Supervisor phone number
Please enter a valid phone number.Format: (000) 000-0000.
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Reason for leaving
May we contact this employer
Previous employer 2
Employer name
Position held
Supervisor name
Supervisor phone number
Please enter a valid phone number.Format: (000) 000-0000.
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Reason for leaving
May we contact this employer
Section 8: References

Please do not list RELATIVES as professional references.
Professional Reference 1
First and Last Name

First NameLast Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
How long have you known this reference?
Professional Reference 2
First and Last Name

First NameLast Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
How long have you known this reference?
Section 9: Background, Screening, and Compliance
Are you willing to complete a Level 2 background screening if selected for employment?
Are you willing to consent to drug testing, if required by company policy or client/program requirements?
Have you ever been convicted for a crime, pled guilty, or pled no contest to a criminal offense?
If yes, please explain. A conviction does not automatically disqualify you from employment?
Are you currently excluded, suspended, or prohibited from working with Medicaid, Medicare, or healthcare-related programs?
Section 10: Ability to Perform Job Duties
Are you able to perform the essential duties of the caregiver/direct support position, with or without reasonable accommodation?
If you answered no, or if you would like to request an accommodation related to the application or hiring process, please explain below.
Section 11: Emergency Contact
Emergency contact name

First NameLast Name
Relationship to applicant
Emergency contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact alternate phone number
Please enter a valid phone number.Format: (000) 000-0000.
Section 12: Referral Source
How did you hear about Devine Care Solutions?
If referred by someone, please list their name.
Section 13: Applicant Certifications and Signature

I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that false, misleading, or incomplete information may result in disqualification from employment consideration or termination if hired. I understand that employment with Devine Care Solutions may be contingent upon successful completion of required background screening, reference checks, employment eligibility verification, and any other required onboarding documents or training. I understand that submitting this application does not guarantee employment.
Name

First NameLast Name
Applicant signature
Today's Date

MonthDayYear
Date
Should be Empty:

Devine Care Solutions Caregiver Employment Application

Position & Availability

Section 3: Work Authorization and Employment Eligibility

Section 4: Driver and Transportation Information

Section 5: Experience & Qualifications

Section 6: Language skills

Section 7: Employment history

Most recent employer

Previous employer 1

Previous employer 2

Section 8: References

Professional Reference 1

Professional Reference 2

Section 9: Background, Screening, and Compliance

Section 10: Ability to Perform Job Duties

Section 11: Emergency Contact

Section 12: Referral Source

Section 13: Applicant Certifications and Signature