Online Employment Application

Qualified applicants are considered for all position without discrimination based upon race, color, religion, sex, national origin, marital status, genetics, or disability. Please answer all questions completely and accurately. Incomplete applications may be rejected.

PERSONAL INFORMATION

Today's Date

Last Name   First Name   Middle Initial

Present Street Address City State Zip Code

Email Address

If you have lived at the above address for less than six (6) months, list your previous address

Phone Number   Are you over 18?    Yes   No

Have you previously applied for a position with Seasons of Care?  Yes  No

If Yes, When?


Have you ever been employed by Seasons of Care?  Yes  No

If Yes, when and position


Are you legally eligible for employment in the United States?  Yes  No

Have you ever worked under a different last name than currently used?  Yes  No

If Yes, please state name and reason of use


Are you able to perform all of the essential duties of the job for which are you applying?  Yes  No

If No, please explain


Have you ever been convicted of a crime?*  Yes  No

If Yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.*


Falsification, misrepresentation and/or omission of criminal convictions are grounds for refusal to hire, or if hired, for dismissal. NOTE: A conviction does not automatically disqualify an applicant from employment.

Position Applyling For

Referral Source

Were you referred by a current employee?  Yes  No

Who?

When are you available to start work?

Salary requirements (please specify)

Have you ever been suspended or placed on probation for performance on your job?  Yes  No

If Yes, please explain


Have you ever been terminated for attendance or tardiness?  Yes  No

If Yes, please explain


EDUCATION

School/College Name and Location Years Completed Did You Graduate?
High School
College
Business/Trade School
Professional School

GENERAL & MILITARY SERVICE

Computer software programs/suites skills (please list)


Foreign language fluency (list proficiency in speaking and writing)


Include U.S. military active duty and reserve duty
From     To     Branch of Service     Rank    

CAREGIVING SKILLS

Please check any certifications you have:
Certified Home Health AideCertified Medical AssistantCertified Medical Technician
Certified Nursing AssistantCPR CertifiedFirst Aid Certification
Geriatric Nursing AssistantPersonal Support WorkerSTNA (School:)
List scholastic achievements and internships:


How would you rate your experience with the following aspects of caregiving?
1=No Experience     2=Some Experience     3=Good Experience    4=Excellent Experience

Bathing/Showering Dementia/Alzheimer's Care Grocery Shopping
Dressing/Grooming Clean Bathrooms Cooking/Meal Prep
Incontinence Care Clean Kitchen Driving
Transferring Mechanical Lift Medication Reminders
Laundry Companionship

HOURS AVAILABLE TO WORK
How many hours per week do you prefer to work?

Do you have any part-time or full-time jobs that you expect to continue while working here?  Yes  No

If yes, where and what hours?


Please indicate the days and times you are available to work:
Work anytime
-Saturday (From-To) -Sunday (From-To) -Monday (From-To)
-Tuesday (From-To) -Wednesday (From-To) -Thursday (From-To) -Friday (From-To)

Years of caregiving experience

Why are you a good caregiver?

EMPLOYMENT

In applying for employment, it is understood that we reserve the privilege of contacting past employers for references.

Are you currently employed? Yes  No

May we contact your present employer? Yes  No

PLEASE LIST ALL JOBS BEGINNING WITH YOUR PRESENT OR MOST RECENT POSITION, INCLUDE ALL SELF-EMPLOYMENT, SUMMER AND PART TIME JOBS.

Company Name Telephone
Address Employed (month and year)
Name of Supervisor From To
Job Title Compensation
Start Last
Full Time Part Time Temporary Reason for Leaving

Company Name Telephone
Address Employed (month and year)
Name of Supervisor From To
Job Title Compensation
Start Last
Full Time Part Time Temporary Reason for Leaving

Company Name Telephone
Address Employed (month and year)
Name of Supervisor From To
Job Title Compensation
Start Last
Full Time Part Time Temporary Reason for Leaving

Company Name Telephone
Address Employed (month and year)
Name of Supervisor From To
Job Title Compensation
Start Last
Full Time Part Time Temporary Reason for Leaving

Company Name Telephone
Address Employed (month and year)
Name of Supervisor From To
Job Title Compensation
Start Last
Full Time Part Time Temporary Reason for Leaving

CERTIFICATION

Please read carefully. If you have any questions regarding this statement, please discuss them with the Human Resources Manager or Care Manager before signing.

I certify that the information contained in this application, and accompanying resume, if any, is true and complete to the best of my knowledge and understand that falsification, misrepresentation and/or omission of information is grounds for refusal to hire or, if hired, dismissal. I authorize any persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, and/or any other information that they may have, with regard to any subjects covered by this application and release all such parties from all liability for any damage that may result from furnishing such information to you."

Intitials

"In the event of my employment, I agree to conform to the rules and regulations of Seasons of Care and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to by Seasons of Care at any time, at Seasons of Care’s sole option and without prior notice to me. I understand that this employment application and any other Seasons of Care documents are not contracts for employment, and that my employment and compensation will be employment at will and can be terminated at any time, with or without cause and with or without notice, at the option of either Seasons of Care or myself."

Intitials

"I understand that Seasons of Care may require me to undergo a pre-employment physical and drug screen test by medical staff and/or agent selected by Seasons of Care and a criminal background check as a condition of my employment and/or continued employment. I further understand that I must successfully pass the drug test and criminal background check to be considered for employment at Seasons of Care. I understand that medical examination and drug screens (random, lost time accidents, and just cause) which are job-related and consistent with Seasons of Care’s business necessity, may be required of me once I am employed. I further release Seasons of Care, including all of its officers, agents, representatives and employees from any and all claims, suits, cause of action, liability and damages associated with or arising from my submission to a drug test and/or medical examination. I also understand that Seasons of Care does maintain a restricted smoking environment."

Intitials

Applicant's Signature      Date