Reliable Home Care in Grand Rapids – West Michigan

Employment Application Process

This employment application includes 6 pages, please ensure you have sufficient time to complete the application since you will not be able to save and return to it later.

Availability

Check each box for the hours you are available to work. If you are unable to work during a particular hour, do not check that box. Every employee is required to work every other weekend. Understand that your availability cannot change in your first 90 days of employment.

12:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 2:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 3:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 4:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 5:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 6:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 8:00 AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 9:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 10:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 11:00AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 12:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 2:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 3:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 4:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 5:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 6:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 8:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 9:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 10:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 11:00PM Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Work Prefereces

Select the areas you are willing to work Ada
Alto
Big Rapids
Caledonia
Cedar Springs
Comstock Park
Coopersville
Dorr
East Grand Rapids
Grand Haven
Grand Rapids SE
Grand Rapids SW
Grand Rapids NE
Grand Rapids NW
Grandville
Greenville
Hastings
Howard City
Ionia
Jenison
Kent City
Kentwood
Lowell
Marne
Middleville
Nashville
Rockford
Sparta
Walker
Wayland
Wyoming

I wish to work Full Time (32+ hours)
Part Time (15-31 hours)
Resource Pool (less than 15 hours)

I prefer to work Mornings Afternoons Evenings

The minimum number of hours I prefer to work is

The maximum number of hours I prefer to work is

Conditions and Diseases

Please select all of the conditions and diseases you have experience with Alcoholism ALS Alzheimer's Anxiety Autism Brain Injury/Closed Head Injury Cancer Cellulitis Cerebral Palsy Congestive Heart Disease COPD/Emphysema Depression Diabetes Epilepsy MS Myalgia Paralysis Paraplegia Parkinson’s Quadriplegia Seizures Strokes Sundowners Syndrome

Skills

Please select all of the skills you possess Bathing/Showering Benevolent Touch Bowel Program Breathing treatments Catheter Care Colostomy bags CPR Certified Feeding Tubes Foley Bags Homemaking Hospice Meal Preparation Personal Care Toileting Vitals Wound Care

Transfer Assistance

Transfer Assistance Experience Gait Belts Hoyer Sara Lift Slide Board Stand By Assist

Other Experience

Please select other types of experience you possess Cat in home Dog in home Clients that smoke

Employment Application - Basic Information

Position(s) Applied for

Date of Application

How did you hear about us?

Last Name

First Name

Middle Name

Address

City

State

Zip

Home Phone

Cell Phone

Email Address *

Questions

What is the best time to contact you at home? Days Evenings

Have you ever filled out an application with us before? Yes No

If so, when did you fill out the previous application

Have you ever been employed with us before? Yes No

Are you currently employed? Yes No

Do you have a valid Drivers License? Yes No

Do you have your own dependable transporation? Yes No

Date you are available to work

What is your desired pay range?

Are there any reasons which would prevent you from perfoming the essential functions of the job for which you are applying?

Do you have US Military Service Yes No

If yes when did your service start and when does / did it end?

In which brance of the Militiary did / do you serve

Education

Highschool

Name & Location of Highschool

Highschool Course of Study

Highschool years completed

Highschool Diploma? Yes No

Name and Location of College

College Course of Study

College years completed

Diploma? Yes No

Name & Location

Course of Study

Years Completed

Diploma? Yes No

Previous Employer 1

Employer Name

Address

Phone

Job Title:

Supervisor:

Reason for Leaving

Start Date

End Date

Starting Hourly rate

Ending Hourly Rate

Work Performed

May we contact? Yes No

Previous Employer 2

Employer Name

Address

Phone

Job Title:

Supervisor:

Reason for Leaving

Start Date

End Date

Starting Hourly rate

Ending Hourly Rate

Work Performed

May we contact? Yes No

Previous Employer 3

Employer Name

Address

Phone

Job Title:

Supervisor:

Reason for Leaving

Start Date

End Date

Starting Hourly rate

Ending Hourly Rate

Work Performed

May we contact? Yes No

Have you ever been convicted of a misdemeanor or a felony crime? Yes No

If yes, please explain

Professioanl Reference 1

Name

Phone Number

Best Time to Call

Occupation

Professioanl Reference 2

Name

Phone Number

Best Time to Call

Occupation

Professioanl Reference 3

Name

Phone Number

Best Time to Call

Occupation

Describe any Specialized skills or training you may have

I certify that the information contained in this application or any resume I have supplied is correct and understand that falsification of this information is grounds for termination in accordance with AngelCare, Inc.’s policy. I certify that the answers given by me to the forgoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I hereby authorize a background check of my past employment, activities, and statements contained in this application
and release from liability and responsibility all persons, companies or corporations supplying such information. I understand that such information may include a record of disciplinary action assessed by previous employers and hereby release such parties from any obligation to provide me with written notification of such disclosure.

I understand that if I have a physical, mental or medical impairment which would interfere with my ability to perform in a position at AngelCare, Inc. but which may be accommodated, the law requires that I notify AngelCare, Inc. in writing of this need for accommodation within 182 days after I become aware or should reasonably have known the accommodation was needed.

I understand that it is AngelCare, Inc.’s policy to maintain a work place that is free from the effects of both legal and illegal drugs and/or alcohol abuse. AngelCare, Inc. may conduct drug testing of job applicants. Should I be considered for employment, I may be contacted regarding the time and location of the drug test. Refusal to take or failing the drug test will disqualify me from considerations for employment.

I understand that in order to be hired, I must establish my legal right to work in the United States. When requested, later in the application process, I will provide
AngelCare, Inc. with documentation establishing my legal right to work.
I agree to conform to the policies and procedures of AngelCare, Inc. I understand that this application is not a contract of employment and that the employer follows an
“employment at will” in that I, or the employer, may terminate my employment at any time for any reason consistent with Local, State or Federal law. I understand that compensation, benefits and AngelCare, Inc.’s policies may be amended modified or eliminated at any time with or without notice. I further understand that no person has any authority to enter into any agreement of employment for any specified period of time or to make any agreement or contract to the foregoing, except by written agreement signed by the President of AngelCare, Inc.

I have read and agree to the Certification paragraph above

Electronic Signature of Applicant - Type your full name

Date of Signature

Short Answer Questions

Explain, in detail, why you are seeking employment as a caregiver (HHA, CNA, MA, LPN, RN)? Who or what has influenced you to do so?

What are your goals for the next 12 months?

Describe the necessary characteristics a successful caregiver needs to have and demonstrate while providing in-home, one-on-one, personal care and homemaking services?

Describe your work ethic and what that means to you.

What aspects of your personal life are NOT appropriate to discuss with a client?

What does professionalism mean to you?

What does reliability mean to you?

Because of the nature of our work ,company policy, and City Ordinance; please complete the following questions

Are you able to lift at least 30 pounds? Yes No

If you cannot lift at least 30 pounds please explain

Do you have any limitation that would not allow you to meet the lifting requirement? Yes No

If you do have a limitation that could prevent you from meeting the lifting requirement, please explain

Have you ever been sanctioned by a health care agency in this state or any other state or foreign jurisdiction? Yes No

Do you hyave any allergies or fears to animals? Yes No

If you do have allergies or fears to animals, please explain

Our company policy states that we run random drug tests; are you opposed to this? Yes No

You may not smoke at or near a client's home. Would this be a problem for you? Yes No

I understand that AngelCare, Inc. will conduct a background investigation with regard to my candidacy for employment. This investigation may include work references and verification of previous employment, educational background, driving records, criminal conviction records, personal references, and other information provided by me during the pre-employment process. I also
understand this investigation may include inquiries into any criminal charges currently pending against me as well as my credit history in any case where such history is relevant to performance of the position for which I am applying.
By my signature below, I authorize the investigation and release of information, including the release to AngelCare, Inc., of any information concerning my previous employment with other employees and any information they may have, personal or otherwise. I hereby release and discharge AngelCare, Inc. and all such former employers and their respective representatives from all
liability for any damages to me or my reputation that may result from furnishing such information to AngelCare, Inc.’s representative. I also herby waive and release any rights to notice I may have under any state’s personnel file or right to know laws.

Applicant Full Name

Social Security Number

Electronic Signature of Applicant - Type your complete name

Date

APPLICANT EEO / AFFIRMATIVE ACTION BACKGROUND FORM

It is the policy of AngelCare, Inc. to provide equal employment opportunity to all qualified applicants for employment without regard to personal characteristics, including race, color, religion, national origin, sex, sexual orientation, age, veteran status or disability. Various agencies of the government require employers to
invite applicants to identify themselves. Completing this form is voluntary and in no way affects the decision regarding your application for employment. Information provided on this form is for statistical purposes. This form is confidential and will be maintained separately from your application form.

Date

Last Name

Middle Name

First Name

Date of Birth

Position Applied for

Referred By

Race / Ethnic Origin White Hispanic 2 American Indian / Native American Black / African American Asian Native Hawaiian / Pacific Islander Other