Allen Cares Adult Family Home

Allen Cares Adult Family Home Application

At-Will Employment

First Name *

Full Middle Name

Last Name *

Ethnicity African AmericanAmerican IndianAsian or Pacific IslanderHispanic or LatinoMiddle EasternWhiteOther

Gender

• Female
• Male
• Other

Date of Birth *

MM/DD/YYY Format

Which position are you applying for? *

• Caregiver
• Volunteer

When would you like to start? *

What shift or hours do you prefer? *

Please list your experience, if any. *

Do you have any credentialing or licensing?

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Position Details

Please check all the resident categories that you are NOT able to work with, and or check the last box. *

• Physically Aggressive
• Verbally Abusive
• Dementia or Alzheimer’s
• Elderly
• Violent
• Assistance with medication
• Correctional Clients
• Developmentally Challenged
• Sexual deviance
• Routine Diaper Changes
• Drug or Alcohol Abuse
• Require Bathing
• Require Cooked Meals
• I can work with anyone as long as I feel safe.

Are you a US Citizen? *

• Yes
• No
• Unsure

Are you authorized to work in the US? *

• Yes
• No

Have you ever been convicted of a felony? *

• Yes
• No
• Unsure

Explanation

Do you have any misdemeanors? *

• Yes
• No
• Unsure

Explanation

May we conduct a Caregiver Background Check? *

• Yes
• No

Driver's License #

May we conduct a DMV Background Check? *

• Yes
• No
• I do not drive

Do you have reliable transportation? *

• Yes
• No
• I use other forms of reliable transportation

What is your expected salary? *

What is you highest level of education? *Some High SchoolGEDHigh School DiplomaSome CollegeAssociate degreeBachelor degree

Most recent Employer *

Job Title *

Employer's Address *

Dates of Employment *

May we contact your Employer? *YesNoYes. However, I was terminated.Yes. However, there was a personality conflict.

Employer

Employer's Address

Job Title

Employer's Address

Dates of Employment

May we contact your Employer?YesNoYes. However, I was terminated.Yes. However, there was a personality conflict.

(OPTIONAL) If you would like to submit a Resume submit here: Cover Letter, Resume, & References

Click or drag files to this area to upload. You can upload up to 3 files.

Have you had a recent TB Test *

• Past 90 days
• Over 90 days ago
• Unsure

Upload TB File (You may provide this later if you wish.)

Click or drag a file to this area to upload.

Have you had a recent Caregiver Background Check? *

Upload Caregiver Background (You may provide this later if you wish.)

Click or drag a file to this area to upload.

How did you hear about Allen Cares?GoogleIndeedGlass DoorZip RecruiterUW ParksideAllen CaresFriendRelative

You may add a reference name here if you choose. (Relationship)

Phone

Email

You may add a reference name here if you choose. (Relationship)

Phone

Email

Military Status

• Currently in the military
• Vetran
• Discharged
• Dishonerably discharged.

Is there anything you would like to add? (Optional)

Did this application process make you feel at ease? 0 being the lowest and 10 being the highest.

Selected Value: 0

Signature (to re-do signature tap x) *

Clear Signature

Submit