Seasons Homecare Application Form

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Office Location

Select Office Location

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Section 1 - Additonal Applicant Information

How did you hear about Seasons HomeCare?

Have you ever worked for or applied with Seasons HomeCare previously? (required)

Yes No

Have you ever had experience related to caregiving? (required)

Yes No

Type of Previous Experience

Are you currently certified as a CNA?

Yes No

Do you have any other related certifications or licenses?

Yes No

Please list other certifications or licenses held

When are you available to work? (required)

Indicate hours you are available to work each day Monday through Sunday

Have you ever been convicted of a criminal offense? (required)

Yes No

If yes, please explain.

Date of Application (required)

County in which you live

Section 2 - Employment History

Are you currently employed, if so where? (required)

What is your schedule with your current employer?

Employer Name, Address and Phone, Position Held (required)

Effective Date *

Expiration Date *

Employer Name, Address and Phone, Position Held

Effective Date

Expiration Date

Employer Name, Address and Phone, Position Held

Effective Date

Expiration Date

Section 3 - Non Relative Personal References

Name and Phone Number (required)

Section 4 - Personal Preferences and Abilities

Do you smoke?

Yes No

Do you mind being around someone who smokes?

Yes No

Do you have a driver's license?

Yes No

Do you have your own car for transportation?

Yes No

Have you had experience or training in transferring an individual ie: from a bed to a wheelchair?

Yes No

Have you received any training or have any experience in caring for an individual who needs assistance with Bathing?

Yes No

Have you received any training or have any experience in caring for an individual who needs assisitance with toileting?

Yes No

Have you ever had training or experience with Alzheimer's or Dementia?

Yes No

Section 6 - Level of Care

Will you assist with companionship which includes transportation, letter writing, escort services, reading, medication reminding, going on walks, grocery shopping, and using telephone (required)

Yes No

Will you assist with homemaking to include cooking and meal preparation, eating, laundry, changing bed linens, remove trash and set out for pick up, water plants, and care for animals (required)

Yes No

Will you assist with attendant care to include ambulation, transfer, getting in and out of bed, toileting, grooming, bathing, and dressing (required)

Yes No

Section 7 - Additional Information

Is there any additional information you would like us to consider for employment with our company

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature