(940) 550-3040
(940) 550-3032
robin@seniorlyyours.com
523 Elm Street, Graham, TX 76450
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Personal Information
Name
First
2nd Initial
Last
Address
Street
Apartment
City
State
ZIP
Phone
Home
Cell
Other
Electronic
Email Address
Date of Birth
Day
Month
Year
SIN
Social Insurance Number
Gender
Male
Female
Language
What languages do you speak?
Emergency Contact
Name
Phone
Education
Formal
Diploma
Certificate
Degree
Other
Informal
Do you have current First Aid Certification (State Level):
Expiry Date
Do you have current CPR?
Expiry Date
Have you taken a Food Safety course?
Other
Other
Restrictions
Work Limitations
List any work limitations that you may have and briefly describe:
Hearing
Yes
No
Describe
Speech
Yes
No
Describe
Lifting
Yes
No
Describe
Health
Yes
No
Describe
Physical
Yes
No
Describe
Emotional
Yes
No
Describe
Other
Yes
No
Describe
Availability for Work
Hours & Days Available for Work
Indicate Days and List Hours Available for Work:
Availability
Full-time
Part-time
Short-notice
Split Shift
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday (From)
Sunday (To)
Monday (From)
Monday (To)
Tuesday (From)
Tuesday (To)
Wednesday (From)
Wednesday (To)
Thursday (From)
Thursday (To)
Friday (From)
Friday (To)
Saturday (From)
Saturday (To)
What is the minimum number of hours you will work in one day?
What is the maximum number of hours you will work in one day?
Type of Work Seeking
Type of Position(s) Preferred
Type
Home Maker
Personal Care
Companion
Live-In
Other
Other (Specify)
Live-in care usually requires that you to in a client's home continuously for 3-4 days at a time every week. Indicate which shifts you will accept:
Weekdays (Monday a.m. to Friday a.m.)
Weekends: (Friday a.m. to Monday a.m.)
Clients Not Willing/Able to Work With
Dementias/Alzheimer's
Smokers
Mental Retardation
Behavioral Disorders
Elderly (over 65)
Children
Physical Disabilities
Pets
Females
Males
Client use of marijuana for medicinal purposes
HIV Positive/Aids
Other
Other (Specify)
Duties Not Willing/Able to Perform
Bathing
Grooming
Oral Care
Dressing
Bowel Care
Bladder Care
Feeding
Ambulation
Housekeeping
Laundry
Meal Preparation
Shopping
Transportation
Medication Reminding
Friendly Reassurance Phone Call/Home Visit
Other
Other (Specify)
Experience
Indicate which of the following you have experience in:
Bathing/Showering
Grooming
Personal Hygiene
Dressing
Bowel Care
Bladder Care
Feeding
Ambulation
Toileting
Housekeeping
Laundry
Meal Preparation
Shopping
Transportation
Medication Reminding
Friendly Reassurance Phone Call or Home Visit
Socialization
Other
Other (Specify)
Assignment Location
Are you restricted in the geographical location you are willing/able to work?
Yes
No
Explain
Transportation
Private Vehicle
Bus
Bike
Other
Other (Specify)
Driver's License
Do you have a valid Driver's License?:
Transporting Clients
Are you willing to transport clients in your private vehicle?
Do you have adequate vehicle insurance?
Are you willing to escort a client in their own vehicle?
Are you willing to escort a client on public transportation?
Comments
Abuse Investigation
Have you ever been investigated for abuse, neglect or domestic violence? If "yes", explain:
Yes
No
Message
Reference Information
Work Related #1 (Last Position)
Company Name
Address
Telephone No. & Email Address:
Supervisor's Name
Position Held
Length of Employment
Reason for Leaving
Work Related #2 (2nd Last Position)
Company Name
Address
Telephone No. & Email Address:
Supervisor's Name
Position Held
Length of Employment
Reason for Leaving
Work Related #3 (3rd Last Position)
Company Name
Address
Telephone No. & Email Address:
Supervisor's Name
Position Held
Length of Employment
Reason for Leaving
Personal #1
Name
Address
Telephone No. & Email Address:
Nature of Friendship (friend, co-worker, family etc.)
Personal #2
Name
Address
Telephone No. & Email Address:
Nature of Friendship (friend, co-worker, family etc.)
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 Seniorly Yours, LLC and I hereby release and discharge any of the above and Seniorly Yours, LLC 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 and a criminal background check.
If further understand that, if hired, I may be required to provide proofthat I am a citizen of the United States or proof that I am currently authorized to work in the United States.
Applicant's Signature
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