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Caregiver Application Central Coast CA
administrator@sprynet.com
2020-05-07T15:23:44-07:00
Thanks for Starting an Application Central Coast
Caregiver Application for San Luis Obispo County and Northern Santa Barbara County
1
General Information
2
Background Information
3
Other Information
4
Work Experience Information
First Name
*
Last Name
*
Phone
*
Email
*
Best way for us to contact you?
*
Email
Text
Phone Call
Address
*
Street Address
Address Line 2
City
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What area are you looking for work in?
*
San Luis Obispo County or Northern Santa Barbara County
Orange County
Phoenix Metro Area, Scottsdale, East Valley
Use pull down menu to select area.
Are you lawfully authorized to work in the U.S.?
*
Yes
No
Do you have consistent access to reliable transportation to get to a work assignment on time?
*
Yes
No
Do you have hands-on experience providing care services?
*
No, not yet.
Less than a year
One to three years
More than three years
Check any certifications or licenses you have.
*
Certified Caregiver
Certified Nurse Assistant
Home Health Aide
LVN/PRN
RN
None of the above
Are you registered with the California Home Care Aide Registry (HCA)?
*
Yes
No
Not a California Caregiver
What days of the week do you want to work?
Select All
Sat
Sun
Mon
Tue
Wed
Thu
Fri
Are there any time restrictions or other information we should know about the days you are avaiable to work?
How many hours per week are you looking for?
*
40+ hours/week
20 - 40 hours/week
20 or less hours/week
What types of shifts are you willing to work?
*
Select All
Hourly shifts
12 hour day shifts
12 hour night shifts
24 hour shifts
Weekends day shifts
Weekends night shifts
What is the time frame you will drive to work a shift over a 15 minute drive?
Select All
15 - 30 minute drive
30 -45 minute drive
45 minutes to 1 hour drive
Use the pull down menu to record your answers.
Do you have experience working with patients with Alzheimer's or other demetia related diseases?
Yes
No
I want to work with these patients
I do not want to work with these patients
Which of the following ambulation/transfer caregiving tasks are you experienced performing?
*
Select All
Minimal assit transferring client
Medium assist transferring client
Heavy assist transferring clients
Using a gait belt assisting a client ambulate
Using a slide board assisting a client with transfers
Using a hoyer lift
Which of the following caregiver duties do you have experience performing?
Select All
Assistance with continence issues and changing continence products
Assistance with ambulation and transfers
Assisting with bathing and showering
Assisting with personal hygiene and dressing and undressing
Meal preparation and cleanup
Laundry and light housekeeping
Do you have experience working with end of life clients?
*
Yes
No
I want to work with end of life clients
I do not want to qwork with end of life clients
Do you use any tobacco products?
*
Yes
No
Do you have any preferences for on the job?
*
No smokers
No dogs
No cats
None of the above
Do you have any allergies that would affect the type of caregiving assingments you can accept? If Yes, please explain:
*
Previous Employment
Most Recent Employer's Name
*
Supervisor's name:
Employer's address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer's telephone number
Dates employed:
Reason for leaving:
NEXT MOST RECENT EMPLOYER'S NAME
*
Supervisor's name:
Employer's address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer's telephone number
Dates employed:
Reason for leaving:
NEXT MOST RECENT EMPLOYER'S NAME
*
Supervisor's name:
Employer's address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer's telephone number
Dates employed:
Reason for leaving:
Certifications
*
By clicking on the corresponding button, I certify I understand Family Home Care, Inc. (FHC) is an equal opportunity employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, national origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, physical or mental disability, or any other legally protected characteristic or practice.
By clicking on the corresponding button, I certify I understand this is a preliminary application and not a contract to employ me. In the event I am employed by FHC, I further understand that my employment is for no fixed time and may be discontinued with or without cause or notice by myself or the company to the maximum extent allowed by law. I understand that no employee or officer or agent of FHC may bind the company by oral or printed statements, including handbooks, benefit books, or bulletins, contrary to the above.
By clicking on the corresponding button, I certify that the information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment if I am hired. I authorize the verification of any and all information listed above.
Comments
This field is for validation purposes and should be left unchanged.
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