Application
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Cell Phone Number
*
-
Area Code
Phone Number
Other Phone Number
-
Area Code
Phone Number
Date of Birth
*
Email
*
example@example.com
How did you hear about us? (Example: Facebook, Indeed, Word of Mouth, etc.)
*
Have you ever been convicted of a misdemeanor/felony?
*
Yes
No
If yes, please explain:
*
Do you have reliable transportation?
*
Yes
No
Are you able to transport clients to community activities?
*
Yes
No
Have you received any speeding tickets within the last 5 years?
*
Yes
No
How many hours would you like to work per week?
*
How many miles are you willing to drive to a client's residence?
*
Work Availability (Click on all that apply)
*
Rows
Day Times
Evenings
Overnights
Unavailable
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Education
*
Rows
Yes
No
Grade School
High School Diploma
GED
College
Do you hold any of the following certifications?
*
Rows
Yes
No
Previously Held
AZ Department of Public Safety Fingerprint Card
First Aid Certification
CPR Certification
Direct Care Worker Certification
Article 9
Prevention and Support
Do you have any professional experience working with disabled individuals? (Please Explain)
*
Describe any training or life skills you have which you can apply to working with disabled individuals.
*
What do you like (or think you would like) about working with the disabled population?
*
What personal rewards do you get when working with someone who is disabled?
*
What would you like least about working with the disabled?
*
Can you work with the following clients?
*
Rows
Yes
No
Men
Teenage Males
Women
Teenage Girls
Young Girls
Can you perform the following duties?
*
Rows
Yes
No
Are you able to perform the essential functions of your job without reasonable accommodation?
Are you able to sit, stand or bend for 1 hour or more?
Do you have the ability to push, pull or lift a minimum of 50lbs. without difficulty?
Are you able to work with a client that smokes?
Are you able to work with a client who have cats in their residence?
Are you able to work with clients who have dogs in their residence?
Can you drive your client short distances?
Are there any foods that you can not prepare for the client?
If there are any foods that you cannot prepare for the client, please describe below:
*
Employment
*
Rows
Yes
No
Part Time
Full Time
On Call
Are you currently employed?
Are you currently employed as a caregiver?
Can we contact your current employer for a reference?
Do you understand we will run a background check?
Most Recently Employed By:
*
Job Title:
*
Reason for Leaving:
*
Job Duties:
*
Rate of Pay:
Immediate Supervisor:
*
Supervisor Phone Number:
*
Employed From:
*
Employed To:
*
Previously Employed By:
Job Title:
Reason For Leaving:
Job Duties:
Rate of Pay:
Immediate Supervisor:
Supervisor Phone Number:
Employed From:
Employed To:
Reference #1:
*
Phone Number:
*
Years Known:
Reference #2:
*
Phone Number:
*
Years Known:
Reference #3:
*
Phone Number:
*
Years Known:
Enter the message as it's shown
*
Signature
Submit
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