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Full Name (Last, First, Middle) *

Who referred you ? *

Address Line 1 *

Address Line 2

City *

State *

Zip Code

Email *

Home Telephone Number

Date You Can Start *

Cellular Number *

Are you 18 years or Older ? *

Yes

Do you have a High School Diploma or GED? *

Yes

Position You Are Applying For *

Home Care Provider

Day Staff

Respite

Desired Starting Salary *

Hours You Can Work ? *

Full Time

Part Time

Are you authorized to work in United States? *

Yes

Have your worked for Summit before ? *

Yes

Do you have a valid driver's license ? *

Yes

Can you transport a disabled individual if the position required it ? *

Yes

Can you travel if the position requires it ? *

Yes

Are there currently any children residing in your household? *

Yes

How many people live in your household? *

Have you, or anyone in your household ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment) *

Yes

If yes, please explain

Have you, or anyone in your household ever been convicted of a misdemeanor? *

Yes

If yes, please explain

Do you, or anyone in your household own firearms or weapons? *

Yes

If yes, please explain

Have you been told the essential functions of the job or have you been viewed a copy of the job description listing the essential functions of the job? *

Yes

Can you perform these essential functions of the job with or without reasonable accommodation? *

Yes

Training Background: Please select the relevant training from the dropdown list below *

MOAB 1

MOAB 2

Relias

CPR and First Aid

Other

If other, please explain

Education

Please add relevant education and training

Highest grade completed *

School/College *

City & State *

Diploma/Degree/Major *

Training relative to position

Work History

Start with your present or most recent employment and work back. (Include paid and unpaid positions)

Job 1

Job Title 1

Employer

Phone Number

Name and title of the immediate supervisor

May we contact this employer ?

Yes

Start Date

End Date

Address Line 1

Address Line 2

City

State

Zip Code

Duties

Final Wage

Reason For Leaving

If you do not have more than one employment history, you may leave this section blank

Job 2

Job Title 2

Employer

Phone Number

Name and title of the immediate supervisor

May we contact this employer ?

Yes

Start Date

End Date

Address Line 1

Address Line 2

City

State

Zip Code

Duties

Final Wage

Reason For Leaving

Employment Questionnaire

Please answer the following questions

Please list three (3) experiences, skills or abilities relative to this position *

Is your home accessible to walkers or wheelchairs ? *

Yes

Are you available 24/7 or prefer someone with a day program ? *

Currently, who makes up your household? Check all that apply.

Spouse

Children

Please list the children ages

Extended Family

Please explain

Pets

Please list types of pets

Others

Please explain

Do you find yourself to be more of a:

Leader

Follower

Teacher

Please explain your answer

Please describe your home and any household rules, if applicable, to this position. Include information about potential allergens (pets, wood stoves,etc.) and neighborhood environment.

House Rules

Allergens

Neighborhood environment

Describe the type of person you would like to live with (Smoker, non-smoker, male, female, active, etc.)

Are you willing to commit yourself in a home provider/roommate situation for at least one year? *

Yes

If a home provider/roommate position doesn't work out , are you interested in other programs? *

Yes

If YES, what programs are you interested in?

If Yes, may we contact you at a later date? *

Yes

Personal or Business References

Do not include relatives or previously lister supervisors

1. Name

Relationship

Years Known

Telephone

2. Name

Relationship

Years Known

Telephone

3. Name

Relationship

Years Known

Telephone

Important *

Please review and agree before signing

I agree to comply with the Agency's rules and regulations if hired.

I understand that my employment may be terminated with or without cause and without notice, at any time, by either the Agency or me.

I authorize the release of background, education, and employment information to the Agency and hold all parties harmless from liability.

If hired, I allow the Agency to provide employment information to prospective employers and certify the accuracy of the information provided in my application.

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Personal

Education

Work History

Job 1

Job 2

Employment Questionnaire

Personal or Business References

Important *

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