Application of Employment Position In Home CarePersonal Care ResidenceFull Name: *First, MI, Last Date: *Phone Number: *Email Address: *Address Line 1: *Address Line 2: City: *ZIP / Postal Code: *State: *Preferred method of Contact: *EmailPhone CallTextHow did you hear about us? *IndeedFacebookOtherReferral (Please Provide Name): Are you a resident of Pennsylvania? *NoYesIf no - Which state are you a resident of? If yes - Have you lived in Pennsylvania for the past two years? *NoYesDo you have a valid Driver's License/State ID? *NoYesID Number: State of ID Number: Have you previously applied for a position with either? *Heritage Hills Retirement CommunityHeritage In-Home Care ServicesNoIf yes - When? Ever dismissed from a job? *NoYesIf yes - Please explain: Are you legally eligible for employment in the US? Proof of employment eligibility will be required if you become employed. *NoYesDo you have a police record in elder abuse? *NoYesIf yes - Please explain: Have you ever been convicted of a felony? *NoYesDo you have a current First Aid card? *NoYesIf yes - Exp. Date: Do you have a current CPR card? *NoYesIf yes - Exp. Date: Please list any other relevant certifications you currently hold: Do you have a High School diploma/GED? *NoYesIf no - Highest grade completed: Date you can start: *Salary Desired: *How many hours a week are you available? *Shift Preferred: *At Heritage Hills Retirement Community and Heritage In-Home Care Services staff are required to work at least one shift every other weekend. Staff are also required to work at least every other holiday (time and a half). Can you work holidays? *NoYesCan you work weekends? *NoYesIf applying for Caregiver/Community Living Assistant Position answer below: Do you have experience with the following? Medication Distribution: NoYesIf yes, what experience and to what level of skill? Documenting Medical Charts: NoYesIf yes, what experience and to what level of skill? Bathing Residents: NoYesIf yes, what experience and to what level of skill? (copy) Cooking: NoYesIf yes, what experience and to what level of skill? Cleaning: NoYesIf yes, what experience and to what level of skill? Laundry: NoYesIf yes, what experience and to what level of skill? Activities: NoYesIf yes, what experience and to what level of skill? Do you posses any other relevant training or skills? NoYesIf yes, what experience and to what level of skill? If applying for the Cook Position answer below: Do you have experience with the following? Cooking: NoYesIf yes, what experience and to what level of skill? Kitchen cleaning: NoYesIf yes, what experience and to what level of skill? Food handling and sanitation skills: NoYesIf yes, what experience and to what level of skill? Dietary skills: NoYesIf yes, what experience and to what level of skill? Inventory skills: NoYesIf yes, what experience and to what level of skill? Do you possess any other relevant training or skills? NoYesIf yes, what experience and to what level of skill? Please list your three most recent employers: (Attach additional sheet with applicable experience if necessary). If you have previously submitted a resume via Indeed, Facebook, etc. or have one to submit today you need only provide information that is not included on your resume. Work Experience 1 Company Name: *Address: *Phone: *Name of Supervisor: *Job Title and Duties: *Date of Employment: From: *To: *Reason for Leaving: *Starting Salary: Ending Salary: Employee Benefits: May we contact this employer to verify your employment? NoYesWork Experience 2 Company Name: *Address: *Phone: *Name of Supervisor: *Job Title and Duties: *Date of Employment: From: *To: *Reason for Leaving: *Starting Salary: Ending Salary: Employee Benefits: May we contact this employer to verify your employment? *NoYesWork Experience 3 Company Name: *Address: *Phone: *Name of Supervisor: *Job Title and Duties: *Date of Employment: From: *To: *Reason for Leaving: *Starting Salary: Ending Salary: Employee Benefits: May we contact this employer to verify your employment? *NoYesPlease list three personal/professional references (do not include family members): Reference 1 Full Name: *Relationship to you: *Phone: *Email Address: *Known how long: *Address line 1: *Address line 2: Reference 2 Full Name: *Relationship to you: *Phone: *Email Address: *Known how long: *Address line 1: *Address line 2: Reference 3 Full Name: *Relationship to you: *Phone: *Email Address: *Known how long: *Address line 1: *Address line 2: Releases: I hereby consent to and authorize the use and reproduction, in print or electronic format by Heritage Hills Retirement Community/Heritage In-Home Care Services, or anyone authorized by Heritage Hills Retirement Community/Heritage In-Home Care Services, of any and all photographs which have been taken for any publicity purpose, without compensation, all images — electronic, negatives and positives, together with the prints are by Heritage Hills Retirement Community/Heritage In-Home Care Services. Applicant Signature: *Date: *Heritage Hills Retirement Community/Heritage In-Home Care Services has the right to require a medical examination and or perform background investigations as deemed necessary, including, but not limited to, an investigation of police records and a protective services background check, A Drug and Alcohol test is required. In Pennsylvania In-Home Caregivers working are required to have a two step PPD completed. A new PPD is required annually on-ly if the employee is at risk of being exposed to M. Tuberculosis. Jf an employee shows a false positive with a PPD test a chest X-ray will be completed. If an employee has a chest X-ray, a new X-ray will be completed every three years. I hereby authorize Heritage Hills Retirement Community/Heritage In-Horne Care Services to perform a Background/FBI Check yvith state and/or local authorities and understand that the information will be considered with this application. I authorize my current and previous employers, schools, or persons named above to give any information regarding my employment or education record. I agree that Heritage Hills Retirernent Home/Heritage In-Home Care and my current and previous employers shall not be held liable in any respect if any employment offer is not tendered, is withdrawn, or my employment is terminated because of falsification of statements answered by me in this questionnaire or interviews. I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have not withheld anything that would, if disclosed, affect this application unfavorably and result in termination of my employment. I also acknowledge that my employment, if offered, is AT WILL and that Heritage Hills Retirement Home/Heritage In-Home Care Services or I may terminate my employment with or without cause. **** I hereby acknowledge that I have read the above statement and understand same. Applicant Signature: *Date: *****My signature below verifies that I have never been dismissed from employment due to abuse of clients or residents. Applicant Signature: *Date: *EmailSubmit
