Elder Care Application for Employment

Please fill out the form below

Name: Date:
Home Address: City Zip Code
Phone: home work cell
Email Address:
Preferred areas for employment:
Are you eligible to work in the U.S.? How were you referred to Babies to Boomers?
Type of position you are seeking (check as many as apply):
Permanent    Full-time    Days    Weekends    24 Hour/Overnight
Temporary    Part-time    Evenings    Live-in    Work around school schedule
 
Days/ Hours Available: Do you have an insured, reliable vehicle?
In case of emergency, please contact: Phone: Relationship to you:
 
EDUCATION:
Degree Dates Institution City State Last Grade
Completed
Area of Study
High School
College
College
Trade School
Other Courses
Have you had CPR? Expiration date:    1st aid? Exp. date:
Have you taken any Elder Care Training?   Home Economics classes?
 
PERMANENT ELDER CARE EXPERIENCE: Please list jobs of 3 months or more, i.e. in-home care, assisted living, retirement home care, etc.
   Dates  Employer & Supervisor  Address  Home/Office Phone
1.
Reason for leaving: Gross Salary
2.
Reason for leaving: Gross Salary
3.
Reason for leaving: Gross Salary
4.
Reason for leaving: Gross Salary
 
CHARACTER REFERENCES: People who know you well. NOT work references
   Name  Address  Home/Office Phone    Length and Nature of Relationship
1.
2.
3.
 
VOLUNTEER WORK: Please list dates and organizations.
1.
2.
3.
4.
 
OTHER WORK EXPERIENCE: Please list your most recent jobs NOT in the elder care field
   Dates  Company  Supervisor/Reference  Daytime Phone    Reason for Leaving
1.
2.
3.
4.
 
Clubs, Professional Associations, Organizational Affiliations:
1.
2.
3.
4.
 
PERSONAL ESSAY Why do you feel you would make a good elder care companion? Please include special skills, activities you like to do, special interests, and details about your personality.
 
Duties: Not willing/able to perform:
Bathing/Showering Housekeeping
Grooming Laundry
Oral Care Meal Preparation
Dressing Shopping
Toileting Transportation
Medication Reminding Other
 
Experience: Indicate which of the following you have experience in:
Bathing/Showering Housekeeping
Grooming Laundry
Oral Care Meal Preparation
Dressing Shopping
Toileting Transportation
Medication Reminding Other
 
Authorization
I understand that the information on this application has been requested for the purpose of evaluating my qualifications for employment by parents, as a child care provider. I also understand that I am not, and will not be an employee of Babies to Boomers.
I hereby authorize you to request reference checks which may include information on my character, education, driving record, police record, past employment, previous addresses, social security number, and credit history.
To the best of my knowledge, the information on this application is true. I understand that misrepresentation or omission of facts in connection with the information provided may be sufficient cause for dismissal wherever discovered.
I permit Babies to Boomers to show this application and all references to parents as a part of the evaluation process.
I agree to release, and hold Babies to Boomers harmless for any act of the employer. I also agree to hold Babies to Boomers harmless of any claim as a result of the placement.
 
NOTICE: We will be requiring criminal, driving, and child abuse screenings. We will also require a credit check, Social Security check, or further screening requested by a family.
DISCLAIMER: There is no guarantee of employment. We reserve the right to reject any candidate.
 
Applicant's Signature  Date
 
Disclosure
This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in section 604 (b) to the Candidate that previous employment, education, social security, credit, motor vehicle report and criminal background check may be obtained for the purpose of this “Application” only.

By the signature below, the “Applicant” acknowledges that Babies to Boomers has made this disclosure.
 
Applicant's Signature  Date
 
 
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