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 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:

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

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:

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