Home at Heart Care Application

Online Application Form
Position Applying For:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
E-mail
Have you been employed at Home At Heart Care?

YesNo
If yes, last date worked
Referral
Referred by H@H Employee:

Employee FirstLast Name
Referred by H@H Client or RP:

Client/RP First NameLast Name
Home at Heart Employee?

YesNo
Home at Heart Client/RP?

YesNo
High School Education:
Name of High School
High School City/State
Did you Graduate?

YesNo
College Education
Name of College
College City/State
Degree Obtained
Other Education
List other education here:
Employment History:
Most Recent Employer
Employer Phone Number

Area CodePhone Number
Dates Worked
Position or Title
Supervisor's Name
Reason for leaving:
Employment History
Employer
Employer Phone Number

Area CodePhone Number
Dates Worked
Position or Title
Supervisor's Name
Reason for leaving:
Employment History
Employer
Employer Phone Number

Area CodePhone Number
Dates Worked
Position or Title
Supervisor's Name
Reason for leaving:
Availability:
What days are you available to work?

SundaysMondaysTuesdaysWednesdaysThursdaysFridaysSaturdays
What times are you available to work?

Morning ShiftsAfternoon ShiftsEvening ShiftsOvernight ShiftsAnytime
Are you available on short notice?

YesNo
Would you want extra hours?

YesNo
Professional References
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Company
City/State
Relationship to you
Can I contact this person?

YesNo
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Company
City/State
Relationship to you
Can I contact this person?

YesNo
Hobbies, Interests, Volunteer Activities
Interests, hobbies and volunteer activities
Caregiver Skills Checklist

I have experience in the following:

Light Housekeeping

	Yes
Laundry
Dishes
Floor Care
Dusting/Vacuum
Bed Making

Meals

	Yes
Food Preparation
Meal Set Up
Feeding
Assist with Feeding

Bathroom Assistance

	Yes
Bed Pan
Toilet
Urinal
Commode
Use of Continence Products

Mobility

	Yes
Wheelchair
Crutches
Walker
Cane
Quad Cane

Positioning

	Yes
In Bed
In Chair
In Wheelchair

Hair Care & Shaving

	Yes
Shampooing
Brushing
Combing
Electric Razor

Transfers

	Yes
Pivot
Slide Board
Gait Belt
In/Out of Bed
In/Out of Commode/Toilet
In/Out of Chair
In/Out of Wheelchair

Bathing

	Yes
Shower
Tub Bath
Bed Bath

Skin & Nail Care

	Yes
Back Rub
Apply Lotion
Filing Toenails
Filing Fingernails

Dressing

	Yes
Dressing
Undressing

Oral Hygiene

	Yes
Mouth Care
Brushing Teeth
Brushing Dentures

Care of

	Yes
Hearing Aides
Eye Glasses

Voluntary Applicant Survey Form

An Equal Opportunity, Affirmative Action Employer
Please read carefully (voluntary disclosure): As an affirmative action employer, we must monitor our equal employment opportunity and affirmative action program, and report these results to government agencies. If you choose not to provide some or all of this information, you will not be subject to any negative or adverse treatment. The information you provide is completely voluntary and will only be used to monitor our compliance with equal opportunity laws and regulations. * The information submitted with this online application will be kept separately from your application.
Race/Ethnicity - Select One or More*

American Indian or Alaskan Native: A person having origins in any of the original peoples of North, South or Central Americas, and who maintains tribal affiliation or community attachment.Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia or Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.Black or African American: A person having origins in any of the black racial groups of Africa.Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South, Central American or other Spanish culture or origin, regardless of race.Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.White: A person having origins in any of original peoples of Europe, the Middle East, or North Africa.Do not wish to answer.
Disability - Are you a person with a disability?*

YesNoDo not wish to answer
Sex/Gender - Select One*

FemaleMaleNon-Binary/Transgender/Gender Non-ConformingDo not wish to answer
I declare that all information provided is true and complete. My digital signature on this document provides permission to contact my references for more information. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
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Online Application Form

Referral

High School Education:

College Education

Other Education

Employment History:

Employment History

Employment History

Availability:

Professional References

Hobbies, Interests, Volunteer Activities

Caregiver Skills Checklist

Voluntary Applicant Survey Form