APPLICATION FOR EMPLOYMENT Please print before you come for interview Page 1
First Time Home Care Agency, 3824 S. Grand, Western Spring IL 60558 708-357-4627 begin_of_the_skype_highlighting 708-357-4627 end_of_the_skype_highlighting
FIRST NAME LAST NAME MAIDEN NAME
PRESENT ADDRESS CITY STATE ZIP
__________________________________________________________________________________ Phone Cell DL # or ID # BIRTH Month,\ Day,\ Year,
Social Security # Green Card # U S Citizen
Live-In _____________Came-Go _________F-T, P-T Days__________________________________________ ENGLISH…………………………………….....................
Nationality________________________________
_______________________________________________$_____________________________________________
Job applied for salary Car Came to U S A. ____________________________
Status____________________________________
_____________________________________________________________________________________________
Grammar School
Smoking__________________________________
____________________________________________________________________________________________
High School hobby ____________________________________
__________________________________________________________________________________________________________________________________________
College University
___________________________________________________________________________________________________________________________________________
Qualifications; Licensed, Certified, Trained, Circle one ; Doctor, LPN, RN, Nurse, PCT, CNA, PTA, CHHA, EKG, Phlebotomy, CPR , Non-Medical
FORMER EMPLOYER
___________________________________________________________________________________________________________________________________________
Name & address of employer phone
Start_________________end_____________________________________________________________________________________________________________________
Position salary
_____________________________________________________________________________________________________________________________________________
Reason for leaving
2____________________________________________________________________________________________________________________________________________
Name & address of employer phone
Start________________end______________________________________________________________________________________________________________________
Position salary
____________________________________________________________________________________________________________________________________________
Reason for leaving
3____________________________________________________________________________________________________________________________________________
Name & address of employer phone
Start _____________end_________________________________________________________________________________________________________________________
Position salary
I agree to pay agency (First Time Home Care ) a single fee, for placement in a suitable position “Acceptance “ means a mutual agreement, verbal or written between employee and employer as to starting salary, position , time and place of employment and fee shall be pay upon accepting a
position offer by an employer.
If I ( applicant ) accept position offer by agency and can not afford pay placement fee, I authorization First Time Home Care Agency to collect My salary
direct from employer.
Agency will charge additional $ 2,25 per mile if I (applicant ) decided to use agency car for any resin .
I attest that I will not take any alcohol or narcotics or any other substances while caring for children or older.
I authorize First Time Home Care to check my reference regarding my past employment history and criminal record .
Application and terms are valid for 5 years, agency will only up date references or phone number if necessary.
CareGiving Requires Dedication and Compassion
........................ __________________ ________________________________________________________________________________
Interviewer Date Applicant agree to above terms signature E-mail
Page 2
___________________________________________________________________________________________________
First
Name
Last name
Which age groups do you work with?
Infant (up to 12 months)
Youth (1-11 years)
Teen (12-17 years)
Adult (18-64 years)
Senior (65+)
Which of the following care services do you have
experience providing? place X
Ambulation | Blood
Sugar Testing | Insulin Injections |
Assistive
Technology/AAC | Body Lifting | Repositioning |
Bathing/Grooming/Hygiene | Brushing
Protocol | Respiratory Care |
Bed Baths | EPI
Pen Injections | Seizure Attendance |
Behavior
- Applied Behavior Analysis | Feeding | Sign
Language |
Behavior - Positive Behavioral Support | G
Tubes | Swimming Attendance |
Other:
Which of the following specific diagnoses do
you have experience caring for?
ADD | Diabetes | Muscular Dystrophy |
ADHD | Down Syndrome | Obesity |
Aspergers | Dwarfism | Pervasive Developmental
Disorder |
Asthma | Dyslexia | Polymicrogyria |
Autism | Epilepsy | Prader Willi |
Autism
Spectrum Disorder | Fetal Alcohol Syndrome | Rett Syndrome |
Blindness/Visual
Impairment | Food Allergies | Seizure Disorder |
Cancer | Fragile X | Sensory Integration
Disorder |
Celiac | Heart
Defects | Speech Delay |
Central
Auditory Processing Disorder | Hydrocephaly | Spinal Cord Injury |
Cerebral Palsy | Mental Illness | Thyroid
Condition |
Cystic Fibrosis | Mental Retardation | Tourette
Syndrome |
Deafness | Mobility
Challenges |
|
Developmental
Delays | Multiple Sclerosis |
|
Other:
Which of the following care services do you have
experience providing?
Ambulation | Blood
Sugar Testing |
Assistive Technology/AAC | Body
Lifting |
Bed Baths | EPI Pen Injections |
Behavior
- Applied Behavior Analysis | Feeding |
Behavior
- Positive Behavioral Support | G Tubes |
Other:
First Time Home Care Agency www.1homecare.net