Healing Hands Senior Care

Bathing & Showering Personal Hygiene & Grooming Dressing Eating & Feeding Ambulation & Transfers Toileting & Incontinence Care Medication Reminders Meal Plan/Prep Laundry Light Housekeeping Errands & Transportation Exercises Grocery Shopping Residence Maintenance Companionship & Support

Position Applied For

Your name if different from: present

Cell Phone / Pager

A. Mention the highest high school grade completed 1,2,3,4,5,6,7,8,9,10,11,12 and Year Completedr

B. If you have not completed high school, do you have equivalency diploma? Yes/No & Date Received.

C. Select Number of years of post high school education

Name & Location of Institution

Hrs

Degree Received

Major

Minor

Dates Attended

May we contact your present supervisor?

Yes No

Job Title

Duties

Employer

Phone

Type of business

Address

Immediate supervisor

Salary(start)

(finish)

Dates Start (mo/yr)

to (mo/yr)

Reason for leaving

Full-time

Part-time

Hours/week

Job Title

Duties

Employer

Phone

Type of business

Address

Immediate supervisor

Salary(start)

(finish)

Dates Start (mo/yr)

to (mo/yr)

Reason for leaving

Full-time

Part-time

Hours/week

Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, special achievements or specialized skills.

S.No
1

2

3

Type License Number

Expiration Date

Granted by (Licensing board)

Type License Number

Expiration Date

Granted by (Licensing board)

List names, addresses and relationships of three persons not related to you who know your qualifications:

S.No
1

2

3

Name

Address / Phone

Relationship

List names, addresses and relationships of three persons not related to you who know your qualifications:

Type License Number

Address / Phone

Relationship

Check which shift you will accept:

Day

Evening

Night

Rotating

Weekends Specify shift hours

Check, which job status you would accept:

Full Time Part-time

Specify

For purposes of compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States?

Yes No

Under the Immigration Reform and Control Act of 1986, your will be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to that effect should you be employed.

Are you willing to provide your own transportation if necessary for your employment?

Yes No

Have you ever been convicted* for any violation(s) of law?

Yes No

Description of offense

Statute or ordinance (if known)

Date of Charge

Date of Conviction

Country, City and State of Conviction

*Convictions include Virginia juvenile adjudications for Capital Murder, First and Second Degree Murder, Lynching or Aggravated Malicious Wounding, If you were age fourteen (14) to eighteen (18) when charged.

When will you be available to start work? (No date is necessary if you are available as soon as you give two (2) weeks notice.)

I herebv certify that all entries are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of the Healing Hands Senior Care, LLC. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employers and educational institutions listed being contacted regarding this application. I further authorize the Healing Hands Senior Care, LLC. To rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need to- know basis for good cause shown as determined by the agency head or designee.

Date

Applicant Signature

Assistance with Basic ADL’s

Bathing & Showering
Personal Hygiene & Grooming
Dressing
Eating & Feeding
Ambulation & Transfers
Toileting & Incontinence Care

Assistance with IADL’s

Medication Reminders
Meal Plan/Prep
Laundry
Light Housekeeping
Errands & Transportation
Exercises
Grocery Shopping
Residence Maintenance
Companionship & Support

Application for Employment

Assistance with Basic ADL’s

Assistance with IADL’s

Healing Hands Senior Care LLC