EmailMe Form - Employment Application

CONTACT INFORMATION:

Name *

First Last

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Home Phone Number

### - ### - ####

Cell Phone Number

### - ### - ####

Email *

Referral Source *

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

What position are you applying for?

BACKGROUND INFORMATION:

Are you over the age of 18?

Yes

No

Are you eligible to work in the United States?

Yes

No

Do you own a car?

Yes

No

Have you ever been convicted of a crime?

Yes

No

List your employment experience here

List your educational experience here

PERSONAL REFERENCE INFORMATION:

Name

Phone

Years Known

AVAILABILITY:

Days Available

Can you cook?

Yes

No

Can you drive clients if needed?

Yes

No

Are you licensed and insured?

Yes

No

Is your care in safe driving condition?

Yes

No

Have you worked for a home healthcare agency before? If so, please explain.

Do you have experience working with Alzheimers patients?

Please read carefully before submitting:

I Authorize Youthful Aging Home Health to check my references regarding past employment history, and to release any information deemed necessary.

I understand I am applying for temporary work and agree to contact Youthful Aging Home Health to check if other work is available. If I do not contact YAHH, you can assume that I am not available to work. Although I may refuse any assignment, I understand that is not always possible for you to keep me working on a continuing basis if I am too selective about my shifts, days or locations.

I will NOT accept any permanent employment from any client to whom I am, or have been, assigned within ninety (90)Days from and after the termination of the last assignment, unless agreed to in writing by Youthful Aging Home Health.

All statements made in this application are true to the best of my knowledge.