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 2505 S. 17th St., Wilmington,NC 28401. Each Home Instead franchise is independently owned and operated. To find a franchise near you, please visit the Become a CAREGiver page.

For job related questions please call the franchise office at 910.342.0455. If you have any technical problems with this site please call 919-508-6147 for technical assistance.

Summary
Title:CAREGiver
ID:1001
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Attachments
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
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:
Screening Questions
* 1. Do you have a valid NC driver's license?
Yes
No
* 2. Do you have reliable transportation?
Yes
No
* 3. Do you have valid insurance for your transportation?
Yes
No
* 4. Are you at lease 21 years of age?
Yes
No
* 5. Are you able to successfully pass a drug test, motor vehicle check, and criminal background check?
Yes
No

**PLEASE READ: Please do not continue to fill out an Application if you answered "NO" to any questions #1-5.  This means you currently do not meet our minimum requirements.  Thank you for your interest in Home Instead Senior Care.

US CAREGiver Employment Application
APPLICANT NOTE
Home Instead Senior Care is an independently owned and operated Home Instead Senior Care® franchise 2505 S. 17th St., Wilmington,NC 28401 910.342.0455

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.


* 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

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.
* Full Time or Part Time (check all that apply):
Full Time   Part Time
* Total hours preferred to work per week:
* Areas of availability (check all that apply):
Hourly   Mornings   Afternoon   Evenings   Overnights   Live-In   Weekends
* How many miles from home are you willing to travel?

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?
* Are you willing to provide service to a client with a pet (please specify cats, dogs, or both)?
Cats   Dogs   Both   Neither
* Are you willing to provide service to a client that smokes?
Yes   No

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
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 had any moving traffic violations?
Yes   No
If yes, please describe:
* Have you been convicted of a felony or misdemeanor in the past seven (7) years?
Yes   No

If Yes, please describe below:
(Conviction will not necessarily disqualify applicant from employment. The recency, severity, and pertinence of the conviction to the job will all be considered.)
Incident City/State Result

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

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date:
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 Home Instead Senior Care, 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:

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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