CarePoint Home Care

 
 
 
 
Employment Application

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, or marital status, or the presence of a non-related medical condition or disability. All required questions must be answered. Any application that does not provide requested information will be automatically rejected.

For this type of employment CarePoint Home Care requires a criminal background check as a condition of employment. Applicants may be tested for illegal drugs.

* Indicates required fields

Personal Information
First Name *
Please provide your First Name
Middle Initial
Last Name *
Please provide Last Name
Street Address *
Please provide Street Address
City *
Please provide City
State *
Please provide State.
Zip Code *
Please provide Zip Code
How long at this address? *
Please add a value for How long at this address?.
Previous Address
City
State
Zip Code
How long at this address?
Primary Phone *
Please provide Home Phone
Other Phone
Best time to call *
Please add a value for Best time to call.
Email *
Please provide a valid Email Address
Date of Birth - dd/mm/yy *
Please provide Date of Birth
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Gender *
Please add a value for Gender.
What language(s) do you speak?

Emergency Contact
Person to contact in an emergency *
Please add a value for Person to contact in an emergency.
Relationship *
Please add a value for Relationship.
Address *
Please add a value for Address.
Primary Phone *
Please add a value for Home Phone.
Other Phone
   

Education
High School
City/State
Graduated
College
City/State
Degree
Major
Business or Trade School
City/State
Degree
Major
Professional School
City/State
Degree
Major

Certifications

Check all that apply. *
Certifications *
Please add a value for Certifications .
Other Certification
   

Restrictions

List any work limitations that you may have and briefly describe.*

Hearing *
Please add a value for Hearing.
Speech *
Please add a value for Speech.
Lifting *
Please add a value for Lifting.
Health *
Please add a value for Health.
Physical *
Please add a value for Physical.
Emotional *
Please add a value for Emotional.
Other *
Please add a value for Other.
If yes to any above, briefly describe:
   

Availability for Work
Hours available for work *
Please add a value for Hours available for work.

Indicate days and list hours available for work:
Sunday (From - To)
Monday (From - To)
Tuesday (From - To)
Wednesday (From - To)
Thursday (From - To)
Friday (From - To)
Saturday (From - To)
Minimum hours you will work in a day? *
Please add a value for Minimum number of hours you will work in a day?.
Maximum hours you will work in a day? *
Please add a value for Maximum number of hours you will work in a day?.
Are you available to work overtime? *
Please add a value for Are you available to work overtime?
Would you consider live-in? *
Please add a value for Would you consider live-in?.
Hourly Range Requested ($)
Date available to start work? ( mm/dd/yy ) *
Please add a value for Date available to start work?.
Are you legally authorized to work in the US? *
Please add a value for Are you legally authorized to work in the US?.
   

Client Types & Work Duties
Types of position(s) preferred (check all that apply) *

Please add a value for Types of Position(s) Preferred .
Other Position
Live-in care usually requires that you reside in a clients home continuously for 3-4 days at a time every week. Indicate which shifts you will accept:
Clients not willing/able to work with (check all that apply
Please add a value for Clients not willing/able to work with .
Other Clients
Experience (check all that apply): *

Please add a value for Experience .
Other Experience
Are you restricted in the geographical location you are willing to work? *
If Yes, briefly explain:
   

Transportation
Transportation type
Do you have a valid Driver's License? *
Please add a value for Do you have a Driver's Licence
Do you have auto insurance
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{driverslicensenum:validation}		 {driverslicensenum:description}
State/Province of issue
Expiration date - mm/dd/yy
Have you had any moving violations during the past 3 years? *
Please add a value for Have you had any moving violations during the past 3 years?.
How many?
If yes, please describe:
Are you willing to transport clients in your private vehicle?
Do you have adequate vehicle insurance?
Are you willing to drive a client's vehicle?
Are you willing to escort a client in their own vehicle?
Are you willing to escort a client on public transportation?
Comments:
   

Criminal Background & Abuse Investigation
Have you ever been convicted of a crime? *
Please add a value for Have you ever been convicted of a crime?.
If "yes", explain number of conviction(s), nature of offenses(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (other than minor traffic violations). A conviction will not necessarily result in denial of employment, however, please note that in order to be hired by Care Point Home Care, you must be bondable.
Have you ever been investigated for abuse, neglect, or domestic violence? *
Please add a value for Have you ever been investigated for abuse, neglect, or domestic violence?.
If yes, briefly explain:
   

Work Experience
Have you previously applied for work at CarePoint Home Care? *
Please add a value for Have you previously applied for work at Care Point Home Care? .
If yes, when?
Have you previously worked at CarePoint Home Care? *
Please add a value for Have you previously worked at Care Point Home Care? .
If yes, when?
Please list your work experiences for the past five years beginning with your most recent job held. If you were self-employed, give company name.

Work Related #1 (Current or Most Recent Position)
Company Name
Address
Name of Last Supervisor
Telephone
Email
Position Held
Job Duties
Pay or Salary (Start - Final) $
Employment Dates (From - To)
Reason for leaving
May we contact your present employer
If NO, please explain why and
please provide us with another work reference:

Work Related #2 (2nd Last Position)
Company Name
Name of Last Supervisor
Address
Telephone
Email
Position Held
Job Duties
Pay or Salary (Start - Final) $
Employment Dates (From - To)
Reason for leaving
May we contact this employer
If NO, please explain why and
please provide us with another work reference:

Work Related #3 (3rd Last Position)
Company Name
Address
Name of Last Supervisor
Telephone
Email
Position Held
Job Duties
Pay or Salary (Start - Final) $
Employment Dates (From - To)
Reason for leaving
May we contact this employer
If NO, please explain why and
please provide us with another work reference:
Please use the space to summarize any
additional comments and other skills,
licenses/certifications and qualifications
(including explanation of any gaps in
employment):
   

More About You
Why do you enjoy caregiving? *
Please add a value for .
Please describe some of your volunteer work: *
Please add a value for describe voluteer work
Do you have any relatives or friends currently employed by CarePoint Home Care? *
Please add a value for do you have relatives employed by CarePoint
If yes, provide their name
Where did you hear about us? (check all that apply) *
Please add a value for Where did you hear about us
   

Personal References

List two personal references. DO NOT LIST relatives or previous supervisors.

Personal Reference 1
Name *
Please add a value for Personal Reference 1 Name
Address *
Please add a value for Personal Reference 1 Address
Telephone *
Please add a value for Personal Reference 1 Telephone.
Email *
is not a valid e-mail address.
Nature of Friendship (friend, co-worker, teacher, etc.) *
Please add a value for Personal Reference 1 Nature of Friendship

Personal Reference 2
Name *
Please add a value for Personal Reference 2 Name
Address *
Please add a value for Personal Reference 2 Address
Telephone *
Please add a value for Personal Reference 2 Telephone.
Email *
is not a valid e-mail address.
Nature of Friendship (friend, co-worker, teacher, etc.) *
Please add a value for Personal Reference 1 Nature of Friendship

I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to CarePoint Home Care and I hereby release and discharge any of the above and CarePoint Home Care from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test ,if part of the Agency’s pre-employment policy.

I understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.


Initials *
Please add a value for .
Date (mm/dd/yy) *
Please add a value for Date.
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