Apply for Care-giver Application

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Care-giver Application
ID:Appl.02
Department:Human Resources
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.
  - or Upload from:
 
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Certificate:
  - or Upload from:
 
Upload your certificate, if any.
Resume:
  - or Upload from:
 
Upload Resume here.
Picture:
  - or Upload from:
 
Upload Picture here.
Child Abuse:
  - or Upload from:
 
Upload Child Abuse Clearance Forms here.
Application for Employment
PERSONAL INFORMATION
* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):
Yes   No
* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):
Yes   No
* Have you ever been convicted of a felony or a misdemeanor within the last seven years? (A conviction will not necessarily result in the denial of employment):
Yes   No
If Yes, please explain:
* Have you ever worked for this Company before?:
Yes   No
If Yes, please provide details (Where/When/Job Title):
* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:
Yes   No
If no, please explain:

EMPLOYMENT DESIRED
* When would you be available to begin work?:
* Type of employment desired:
Full-Time
Part Time
Seasonal
* Hourly rate/salary desired:
* Are you currently employed?:
Yes   No
If so may we inquire of your present employer?:
Yes   No
If presently employed, why are you considering leaving?:

EDUCATION
Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location Did you Graduate? Degree Received Subjects Studied/Major
Yes   No
Yes   No
Yes   No

If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

EMPLOYMENT HISTORY
Give your full employment record, starting with your current or most recent employment

EMPLOYER 1

Dates Employed Employer Name & Address Employer Phone
From:

To:

Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

EMPLOYER 2

Dates Employed Employer Name & Address Employer Phone
From:

To:

Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

EMPLOYER 3

Dates Employed Employer Name & Address Employer Phone
From:

To:

Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

REFERENCES Please provide three professional references (not friends or relatives).

Name Relationship Phone Number Email

AUTHORIZATION
The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):
* Date:
Schedule
Please advise ALL times you are available to work Care-giving Shifts
* Are you available to Work MONDAY - 7:00 AM to 12:00 PM?
Yes
No
* Are you available to Work TUESDAY - 7:00 AM to 12:00 PM?
Yes
No
* Are you available to Work WEDNESDAY - 7:00 AM to 12:00 PM?
Yes
No
* Are you available to Work THURSDAY - 7:00 AM to 12:00 PM?
Yes
No
* Are you available to Work FRIDAY - 7:00 AM to 12:00 PM?
Yes
No
* Are you available to Work MONDAY - 12:00 to 5:00 PM?
Yes
No
* Are you available to Work TUESDAY - 12:00 to 5:00 PM?
Yes
No
* Are you available to Work WEDNESDAY - 12:00 to 5:00 PM?
Yes
No
* Are you available to Work THURSDAY - 12:00 to 5:00 PM
Yes
No
* Are you available to Work FRIDAY - 12:00 to 5:00 PM
Yes
No
* What WEEKNIGHTS 6 PM  to 12:00 AM are you available?
* Are you available to work SATURDAYS?
Yes
No
* Are you Available to work SUNDAYS?
Yes
No
* Is there anything else we should know about your availability to work care-giving shifts?
Americans with Disabilities Act
EQUAL OPPORTUNITY EMPLOYER/AMERICAN WITH DISABILITIES ACT
It is the policy of Samaritans At Last to be an equal opportunity/affirmative action employer. Our Organization adheres to and supports all laws regarding discrimination. An objective of our organization is to recruit, hire, train and promote into all job levels the most qualified applicants without regard to race, color, creed, religion, sex, age, national origin, marital status, sexual orientation, disability, veteran status, or political beliefs. All such decisions are made by utilizing objective standards based on an individual's qualifications as they relate to a particular job vacancy and to the furtherance of equal employment opportunity. Samaritans At Last is committed to providing equal opportunities to otherwise qualified individuals with disabilities, which may include providing reasonable accommodations where appropriate.

APPLICANTS STATEMENT
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application or in an interview for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 3 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing.

In the event of employment, I understand also that false and misleading information given in my application or interview(s) may result in discharge. I understand also that I am required to abide by all rules and regulations of the Employer and in conjunction with any contractual arrangements.

I consent to any and all job-related examinations, including pre-employment health, drug screening, and criminal background checks as required by Samaritans At Last. I understand that if I am employed I will be on probationary basis for 3 months from the date of employment. Upon my termination I authorize the release of reference information on my work.

I understand that I shall provide/produce the necessary PA STATE POLICE Criminal History Checks including Child Abuse Clearance within 30 days of initiation of employment. (If unreported convictions are revealed in your Pa State Police criminal history check or child abuse registry, the offer of employment will be withdrawn and, if employed, you will be separated from employment, unless you show that the report is in error. If convictions are revealed in the child abuse registry within five (5) years from the date of enrollment, your job offer of employment will be reversed.)

If you have not been a resident of the commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, you shall obtain a Federal criminal history record and a letter of determination from the Department of Aging, based on the your Federal criminal history record, in accordance with 6 Pa. Code 15.144(b) (relating to procedure). The decision to reject or terminate an individual with an unreported conviction is solely at the discretion of Samaritans-At-Last. (All related information will be treated as confidential, and protected as such.)

I authorize the release of any work-related information to Samaritans At Last to include: Dates of employment, performance evaluations, attendance records, and any related information necessary for employment consideration.

I fully understand and accept all terms and conditions in the above statement.

* Name:* Phone:* Date:

Elder Abuse Policy
Elder Abuse and Neglect Policy

At Samaritans-At-Last, we take it very seriously when it comes to elderly abuse and neglect. It is therefore the policy of SAL to ensure that such incidences never occur under our watch.

As a caregiver/employee I pledge to abide by the rules and the behavior that don't tolerate elder abuse and neglect. I also understand that by signing on this policy that I will be liable for any consequences that may result if found guilty of abuse and neglect of clients. SAL has zero tolerance on neglect and abuse policy; therefore, if elder abuse and neglect is evident the offer of employment will be withdrawn, and criminal charges may be filed against you. Any monetary expenses thereof will be upon you.

* Employee Name:* Date:

Arbitration Policy
Acknowledgment of and Agreement with Arbitration Policy

My signature on this document acknowledges that I understand the Arbitration Policy as it is listed in the SAL Employee Manual that I was issued I agree to abide by its conditions. I also acknowledge that I understand my employment is at-will and my termination at any time, with or without reason, by either SAL or myself. I further agree that I will submit any dispute including but not limited to my termination arising under or involving my employment with SAMARITANS AT LAST, LLC to binding arbitration within one (1) year from the date the dispute first arose. I agree that arbitration shall be exclusive forum for resolving all disputes arising out of or involving my employment with SAL or the termination of that employment. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.

* Employee Name:* Date:
Company Officer:Date:

Medication Policy
Medication Policy

This policy is to be read by all employees of SAMARITANS AT LAST, LLC, D.B.A SAMARITANS AT LAST.

SAMARITANS AT LAST is a non-medical, in-home care company. The dispensing, instruction of a medication(s), or the filling of a client's medication box, by any employee of SAMARITANS AT LAST is strictly forbidden. If a client asks you to fill their medication box or open bottles of medication for them, you must have a family member do it or other responsible party.

Failure to adhere to this policy will result in disciplinary action.

* Employee Name:* Date:
Company Officer:Date:

Your Personal File
Name

Last Name First Name Middle Name
Address City State and Zip

Phone Number
Daytime Number
Person to call in case of emergency

Last Name First Name Middle Name
Address City State and Zip

Phone Number
Daytime Number
Number of Dependents
Marital Status:
Single   Married
Change of Beneficiary:
Driving record or status of driver's license:
Exemptions on your W-4 tax form:
Training Certificates:
Has Caregiver been tested for PPD?
Yes   No
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond

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