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 1401 State Street, New Albany, IN 47150. 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 812.948.9770. If you have any technical problems with this site please call 919-508-6147 for technical assistance.

Summary
Title:CAREGiver
ID:1002
Department:Client Services
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Home Phone:
* Cell Phone:
* Work Phone:
* Alternate 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:
CAREGiver Screening Questions
* 1.  Are you 21 years of age or older?
Yes
No
* 2.  Are you authorized to work in the United States for any employer (i.e. satisfy Employment Eligibility Verification Form I9)?
Yes
No
* 3.  Do you have previous caregiving experience as a professional, volunteer and/or family caregiver which includes having assisted with personal care tasks such as bathing and toileting/changing adult diapers?
Yes
No
* 4.  Can you provide professional and personal references that can be verified?
Yes
No
* 5.  Do you have a safe, clean and reliable automobile available to you at all times?
Yes
No
* 6.  Do you have valid auto insurance with appropriate liability coverages that lists you as an authorized driver?
Yes
No
* 7.  Can you pass a drug screen?
Yes
No
* 8.  Are you able to lift, push, pull or carry up to 25 pounds which is an essential function of the job for which you are applying?
Yes
No
* 9.  Are you able to perform activities that require kneeling, bending, twisting, reaching, carrying or stooping, all of which are essential functions of the job for which you are applying?
Yes
No
* 10. In the last 7 years, have you had any moving traffic violations and/or have you had your license suspended?
Yes
No
If yes, please explain.
* 11. Have you ever been convicted of a felony and/or misdemeanor?
Yes
No
If yes, please explain. For this type of employment state law requires a criminal background check as a condition of employment. Conviction will not necessarily disqualify applicant from employment. The recency, severity and pertinence of the conviction to the job will all be considered.
* 12. What pay rate do you require? Please use a range.  For example, From $8.00 to $8.50 per hour.

**PLEASE READ**: Please do not continue to fill out an application if you answered "no" to any of questions #1 through #9 ONLY. 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
CH Services, Inc. is an independently owned and operated Home Instead Senior Care® franchise 1401 State Street, New Albany, IN 47150 812.948.9770

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
* Social Security Number:
* Home Phone:
* Cell Phone:
List previous addresses for the last 7 years starting with the most recent (Street/City/State/Zip):
* Valid Driver’s License #: * State Issued: * Exp. Date:
* Make of Vehicle, ie Honda:
* Model of Vehicle, ie Civic:
* Auto Insurance Company:
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?

AVAILABILITY
Due to the nature of this industry, no guarantee can be made as to the schedule or the amount of hours worked. Also please note, we rely upon the availability you state below when making our hiring decision. If your availability changes from what is stated below during the hiring process or at any time during your employment, you must contact our office immediately with the change. Depending upon the change, Home Instead Senior Care reserves the right to not further consider you for employment or, in the case of a current employee, you may be subject to discipline up to and including termination.

* What date are you available to begin work?
Please Complete all Areas of Availability.
* Total hours preferred to work per week:
* Hours of availability (check all that apply):
Hourly   Mornings   Afternoon   Evenings   Overnights   Live-In   Weekends
Our service territory includes Clark and Floyd counties of southern Indiana.
* How many miles from home are you willing to drive to an assignment?
* Are you available to work at least one weekend per month?
Yes   No
Please use the space to elaborate about your weekend availability.

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
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
Alzheimer’s 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 person’s stability and safety when moving)
*
Yes   No
Willing to Learn
Mechanical Lift (Hoyer Lift)
*
Yes   No
Willing to Learn

* Can you lift, push or pull up to 25 pounds, an activity that is an essential function of the job for which you are applying?
Yes   No
* Can you perform activities that require kneeling, twisting, reaching, carrying, bending or stooping, all of which are essential functions of the job for which you are applying?
Yes   No

JOB RELATED SKILLS
* Describe any training, certificates/licenses (e.g. CNA, LPN, LVN etc.) and/or life skills you have that apply to caring for a senior:
* Describe any NON-PAID experience you have in providing care to a senior, including caring for a family member:
* What is the most challenging aspect about working with seniors?:

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.
If you do not have a second or third employer enter N/A in the required fields.

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:

FOURTH 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:

FIFTH 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
For this type of employment, state law requires a criminal background check as a condition of employment. In addition, 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?
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 family.

Professional References
Full Name Phone Number Best Time of
Day to Call
Relationship Number of
Years
Known
*
*
*
AM   PM
*
*
*
*
*
AM   PM
*
*
*
*
*
AM   PM
*
*

Personal References - Do Not Include Family
Full Name Phone Number Best Time of
Day to Call
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 the employment application 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 called for in this application may result in rejection of my application or discharge at any time during my employment.

I understand that this application is not a contract of employment and that if hired, regardless of any oral representations to the contrary, the employment relationship between CH Services, Inc. dba Home Instead Senior Care (“Home Instead”) and myself is terminable at will.

I understand that the use of illegal drugs is prohibited during employment. If Home Instead policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

Electronic Signature Agreement

By selecting the "submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide disclosures or conditions constitutes your signature hereafter referred to as ("E-Signature"), as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.

* Signature (type full name):
* Date:
Background and Reference Check Authorization
HOME INSTEAD SENIOR CARE BACKGROUND AND REFERENCE CHECK AUTHORIZATION, CONSENT AND WAIVER

I authorize CH Services, Inc. d/b/a Home Instead Senior Care ("Home Instead") and/or its agents to make whatever inquiries it may deem necessary in connection with my course of employment. As part of such inquiries, Home Instead has my permission to conduct an investigation of my background, references, character, employment, motor vehicle, education, and criminal history record information.

A history of a conviction of crime will not necessarily disqualify an applicant from employment. As related to the position applied for, a review of the age and time of the offense, seriousness and nature of the violation, rehabilitation or current state law requirements will be taken into account.

I authorize Home Instead to obtain a consumer report, which may consist of criminal background information and investigative reports bearing on job performance. I agree and understand Home Instead may obtain information which may be in any state or local files, including those maintained by both public and private organizations, and all public records, for the purpose of confirming the information contained in my application and/or obtaining other information which may be material to my qualifications for employment. I also authorize Home Instead to obtain any and all information from former employers including, but not limited to, performance, achievement, attendance, disciplinary information, reason for termination, and work history. I further authorize Home Instead to provide a copy of this document to any such former Employer (or current or former employee or agent thereof) and direct such party to release such information to an authorized employee of Home Instead regardless of any agreement between us to the contrary or any other policy to the contrary. I further authorize Home Instead to perform reference-checking conversations with individuals whose names I provide, as well as with any other people whose names I have not provided.

I agree a telephone facsimile (fax) or xerographic copy of this Home Instead Senior Care Background and Reference Check Authorization, Consent, and Waiver ("Consent") shall be considered as valid as the original consent. In the event of my employment by Home Instead, this authorization shall remain in effect for the duration of such employment.

I authorize and release individuals, business entities, references, current and former employers and their current and former employees, schools, credit bureaus, municipal, county, state and federal agencies and courts, to provide all information that is requested to Home Instead or its authorized agents. I further release and hold harmless all of the above, including Home Instead and its agents and employees, from any liability or claims arising from retrieving and reporting of information concerning me. I specifically waive any entitlement to be notified prior to the provision of such information by my references, former employers (including their employees, agents, representatives, or former employees), and any other individuals whom Home Instead may seek to contact.

Information contained in reports obtained by Home Instead in accordance with the 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 Home Instead completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing to the human resource department within a reasonable period of time after your application for employment is received. I hereby acknowledge that I have read, understood and agree to the above Certification and Authorization, Consent and Waiver statements.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT FOR EMPLOYMENT

Electronic Signature Agreement

By selecting the "submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide disclosures or conditions constitutes your signature hereafter referred to as ("E-Signature"), as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.

* Signature (type full name):
* Date:
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

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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