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Home
About
Team
Why choose YHA
Services
Growing Families
Professionals
Outpatients
Students
Faculty Members
Senior Care
Companionship
Dementia Care
Parkinson’s Disease Care
Stroke Recovery
End of Life Care
Diabetes Care
Respite Care
Chronic Conditions Care
Post-Hospital Care
Veterans Care
PCAFC
Contact Us
Request a Consultation
Your Home Assistant
Job Application
First Name
Last Name
Email
Mobile Phone
Address
Experience
PREVIOUS ASSISTANT/CAREGIVER EXPERIENCE #1
Organization
Contact Person
Telephone
Dates Worked
May We Contact?
Yes
No
PREVIOUS ASSISTANT/CAREGIVER EXPERIENCE #2
Organization
Contact Person
Telephone
Dates Worked
May We Contact?
Yes
No
Professional Reference #1 (do not include family or friends)
Position/Title
Telephone
Dates Known
Professional Reference #2 (do not include family or friends)
Position/Title
Telephone
Dates Known
Criminal History
Have you ever been convicted of any felony or misdemeanor offenses?
Yes
No
If yes, please describe the date and nature of the offense.
Education History
Location
Major
Graduate?
Yes
No
End Date
HIGH SCHOOL
Location
Graduate?
Yes
No
End Date
General Availability: Are you available for all hours?
Yes
No
Which days of the weeks are you available?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Skills and Preferences: Please check any you are willing to work with
Growing Families
Companionship
Gait Belt
Smoking
Cats
Newborn Children
Professionals
Incontinence
Males
Children
Bathing/Dressing
Driving
Females
Outpatient
Hoyer Lift
Transfer Assist
Dogs
Please check any you have experience with
Hoyer Lift
Alzheimer's/Dementia
Gait Belt
Children
Incontinence
Transfer Assist
Specialized Training: List any additional certifications you hold
Additional Questions: Do you have access to reliable transportation?
Yes
No
Are you a smoker?
Yes
No
How did you hear about us?
Tell us about recent assistant/caregiving experiences.
Why do you want to be an assistant with us?
Emergency Contact Information
EMERGENCY CONTACT #1
Relationship
Phone
Type
Mobile
Home
Phone Alt
Type
Mobile
Home
EMERGENCY CONTACT #2
Relationship
Phone
Type
Mobile
Home
Phone Alt
Type
Mobile
Home
CERTIFICATION AND RELEASE
I certify that the information provided above is true and complete to the best of my knowledge. I affirm that no misrepresentation or omission has been made regarding my qualifications or background. I understand that any false statement, omission, or misrepresentation may result in the rejection of my application or, if employed, termination at any time during my employment. I authorize Your Home Assistant to verify all information contained in this application, including, but not limited to, criminal background checks and motor vehicle driving records. I also authorize any persons, schools, current or previous employers, and law enforcement agencies to provide relevant information regarding my background. I hereby release all such parties from any and all liability that may result from providing this information. I understand that the use of illegal drugs is strictly prohibited during employment. I am willing to submit to drug testing at any time, either prior to employment or during my employment, to ensure compliance with this policy.
I Agree
RESTRICTIVE COVENANT
I agree that I will not engage in any direct business dealings with any individual or business entity that Your Home Assistant has introduced to me, either through referral or in the course of my employment. I further agree not to seek or accept employment, contracts, or any form of business relationship with such individuals or entities without the prior written consent of Your Home Assistant.
I Agree
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