Apply for CAREGiver

Hello and thank you for your interest in Home Instead Senior Care. Please fill out the application below and click the Submit button when finished. Fields with an asterisk (*) are required.

Completing the application is the first step in the process and when that is completed you will be guided to the second and final part of the application process, an on-line CAREGiver Assessment.

Please note that this is the job board for the franchise office located at 1500 Oxford Drive, Suite 10, Bethel Park, PA 15102. Each Home Instead franchise is independently owned and operated. To find a franchise near you, please visit the Careers page.

For job related questions please call the franchise office at 412-595-7554. If you have any technical problems with this site please call 919-508-6147 for technical assistance.

Summary
Title:CAREGiver
ID:1029
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
Cell Phone:
Work Phone:
* Email:
* Social Security Number:
* Date of Birth:
Attachments
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Additional Information
* How did you hear about Home Instead Senior Care?
If applicable, please specify:
US CAREGiver Employment Application 3
APPLICANT NOTE
Greater Pittsburgh Assisted Living Services, Inc is an independently owned and operated Home Instead Senior Care® franchise located at 1500 Oxford Drive, Suite 10, Bethel Park, PA 15102 Phone: (412) 595-7554

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.
  • Please read "Applicant Note" below.
  • Complete all parts of this application.
  • Application will be valid for 60 days.


Applicant Note: This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead Senior Care franchise. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body is required prior to employment.


PERSONAL INFORMATION
Other Names Previously Used:
  Last Name First Name Middle Name
1.
2.


Emergency Contacts:
  Name Phone Relationship
1.
*
*
*
2.
*
*
*


* Why do you want to become a professional caregiver?
* Have you ever submitted an application here before?
Yes   No
If yes, when?
* Have you ever been employed here before?
Yes   No
If yes, when?
* Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?
Yes   No
* Do you have a reliable vehicle in order to travel to/from client home?
Yes   No
* Do you have current automobile insurance on this vehicle?
Yes   No
* Do you have a valid PA driver's license?
Yes   No
* Driver's License Number:* Expiration Date:

AVAILABILITY
Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

* What date are you available to begin work?
Please Complete all Areas of Availability.
* Total hours preferred to work per week:
* Regular work availability (check all that apply):
Hourly   Mornings   Afternoon   Evenings   Overnights   Live-In   Weekends
Please indicate the days of the week as well as the earliest and latest times that you are available for work.

Day From To And/Or From To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
* If hired, all CAREGivers that do not have Saturday or Sunday listed as Regular Work Availability are required to work at least two (2) weekends per month.  Are you able to work at least two (2) weekends per month?
Yes   No

CAREGIVING EXPERIENCE
Please indicate those tasks in which you have experience. For the areas that you do not have experience, please note if you are willing to learn.

Tasks Experience
Yes/No
Willing to Learn
Companionship/Conversation
*
Yes   No
Willing to Learn
Meal Preparation (meals/snacks)
*
Yes   No
Willing to Learn
Housekeeping (dust, vacuum, laundry)
*
Yes   No
Willing to Learn
Bathing/showering Assistance
*
Yes   No
Willing to Learn
Dressing Assistance
*
Yes   No
Willing to Learn
Showering Assistance
*
Yes   No
Willing to Learn
Medication Reminders
*
Yes   No
Willing to Learn
Hospice Care
*
Yes   No
Willing to Learn
Stroke Care
*
Yes   No
Willing to Learn
Dementia Care
*
Yes   No
Willing to Learn
Incidental Transportation & Errands
*
Yes   No
Willing to Learn
Incontinence Care
*
Yes   No
Willing to Learn
Personal Care Assistance (Female)
*
Yes   No
Willing to Learn
Personal Care Assistance (Male)
*
Yes   No
Willing to Learn
Alzheimerís or Dementia Care
*
Yes   No
Willing to Learn
Diabetes Care
*
Yes   No
Willing to Learn
Hearing Impairment
*
Yes   No
Willing to Learn
Transferring Assistance
(Example: helping a person from chair to standing position)
*
Yes   No
Willing to Learn
Ambulation Assistance
(Example: Ensure a personís stability and safety when moving)
*
Yes   No
Willing to Learn
Mechanical Lift (Hoyer Lift)
*
Yes   No
Willing to Learn


* How many yearís experience do you have as a Caregiver?

EDUCATION
Please check the highest grade level completed:

Grade School:
6   7   8
High School:
9   10   11   12
College:
13   14   15   16   16+

  Name City, State Major Subjects # Yrs Attended Graduate?
High School
*
*
*
*
Yes
No
Vocational/Technical
Yes
No
College/University
Yes
No

WORK HISTORY
Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER

* Are you currently working for this employer?
Yes   No
* If yes, may we contact?
Yes   No
* Company Name:
* City:
* State:
* Company Phone:
* Dates Employed - From:
* Dates Employed - To:
* Job Title:
* Supervisor's Name:
* Duties:
* Salary:* Per Hour/Week/Month:
* Reason for Leaving:

SECOND MOST RECENT EMPLOYER

* Are you currently working for this employer?
Yes   No
* If yes, may we contact?
Yes   No
* Company Name:
* City:
* State:
* Company Phone:
* Dates Employed - From:
* Dates Employed - To:
* Job Title:
* Supervisor's Name:
* Duties:
* Salary:* Per Hour/Week/Month:
* Reason for Leaving:

THIRD MOST RECENT EMPLOYER

* Are you currently working for this employer?
Yes   No
* If yes, may we contact?
Yes   No
* Company Name:
* City:
* State:
* Company Phone:
* Dates Employed - From:
* Dates Employed - To:
* Job Title:
* Supervisor's Name:
* Duties:
* Salary:* Per Hour/Week/Month:
* Reason for Leaving:

BACKGROUND INFORMATION
As a condition of employment, all employees must be "Bondable".

List states and counties of residence for the past seven (7) years:
* County:* State:
County:State:
County:State:
County:State:

* Have you ever had any moving traffic violations?
Yes   No
If yes, please explain giving year and violations:
* Do you have any pending criminal action at this time?
Yes   No
If yes, please describe:
* Have you ever been convicted of a felony and/or misdemeanor?
Yes   No
If yes, please describe:


REFERENCES
Please complete all six references (three professional/three personal). Your application will not be considered unless six references are provided. Since we will contact these references, please notify them in advance. Do not include relatives.

Professional References
Full Name Phone Number Best Time of
Day to Call
Email Relationship Number of
Years
Known
*
*
*
AM   PM
*
*
*
*
*
*
AM   PM
*
*
*
*
*
*
AM   PM
*
*
*

Personal References
Full Name Phone Number Best Time of
Day to Call
Email Relationship Number of
Years
Known
*
*
*
AM   PM
*
*
*
*
*
*
AM   PM
*
*
*
*
*
*
AM   PM
*
*
*
CERTIFICATION AND RELEASE
I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT FOR EMPLOYMENT

* Signature (type full name):
* Date:
PA RESIDENCY REQUIREMENT
* Have you been a resident of Pennsylvania for a minimum of 2 years?
Yes
No

If No, List CITY, STATE, COUNTY and DATES resided for past 3 Years.

#1 CITY, STATE, COUNTY and DATES resided
#2 CITY, STATE, COUNTY and DATES resided
#3 CITY, STATE, COUNTY and DATES resided
PROFESSIONAL CERTIFICATIONS
Please indicate if you have any of the following professional licenses (RN,LPN,CNA, etc.)
License Title
State License was attained
License #
License Expiration Date
Is this license currently active or inactive?
U.S. Release & Authorization for CBC & Drug Test
Release Authorization


* Last Name:* First Name:Middle Initial:
Maiden/Previous Names: 
* Home Address:* City:
* State:* Zip Code:
* Social Security Number:* Date of Birth:
Driver's License Number:Issuing State:


Authorization to Secure Consumer Investigative Report

I authorize Greater Pittsburgh Assisted Living Services, Inc, d.b.a. an independently owned and operated Home Instead Senior Care franchise, to make whatever inquiries it may deem necessary in connection with my course of employment. As part of such inquiries, Employer has my permission to contact persons who may have information regarding my suitability for employment and to secure consumer reports (including investigative consumer reports).

I authorize and instruct any person or agency contacted to participate or conduct inquiries at its request, to compile information, and to furnish any information obtained as a result of such inquiries.

I further authorize Employer, in its sole discretion, to furnish copies of this authorization and my application to any person and/or consumer-reporting agency in connection with above purposes.

Authorization for Drug Screening

I consent to drug testing designed to detect the presence of alcohol or the illegal use of drugs.



Disclosure Statement

Information contained in reports obtained by Employer in accordance with above authorization may include information pertaining to your character, general reputation, police record, personal characteristics, and mode of living. You have the right to request that Employer completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing within a reasonable period of time after your application for employment is received.

I hereby acknowledge that I have read and understand the above disclosure statement.

* Signature (type name):
* Date:
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond

After you Submit this application you will be prompted to complete an online CAREGiver Assessment. This is the second part of the application process and will complete your application. Once completed, your information will be reviewed.
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