EMPLOYMENT APPLICATION

Part-Time In-Home Respite Care Provider (Caregiver) for Intellectually Disabled Individuals

Minimum Qualifications

In order to perform these functions and meet the requirements put forth by the California Department of Developmental Services, applicants for the In-Home Respite Care Services provider position must:

1) Able to legally work in the United States;

2) 18 years of age or older;

3) Have a high school diploma or GED;

4) Have unexpired CPR/First Aid Certificate

5) Able to pass a background check and receive a fingerprint clearance card from the authorized agency;

6) Able to provide 3 verifiable non-family references including one previous employer.

7) Have a vehicle with a valid driver's license to drive to the client's home.

8) Must be computer literate; must have an email address and other technology devices needed for communication with families and agency personnel, and have an ability to access the internet to submit required documentations electronically.

Required Knowledge, Skills, and Ability

Because of the essential duties and responsibilities of the In-Home Respite Care Service provider position, applicants for the position must:

1) Able to lift up no more than 40 lbs.; be able to walk, bend, squat, turn in the knees, back, wrists and shoulders, and grasp with both hands (in order to properly perform the techniques taught in CPR/First Aid, Client Intervention Techniques, and Lifting and Carrying Techniques);

2) Able to see and hear with or without correction;

3) Able to speak, read, and write English;


Applicant Information

Are you a citizen of the United States?
Yes No
If no, are you authorized to work in the U.S.?
Yes No
Have you ever worked for this company?
Yes No
Have you ever been convicted of a felony?
Yes No

Education

Did you graduate?
Yes No
Did you graduate?
Yes No
Did you graduate?
Yes No

References

References Please list three professional references.



Previous Employment

May we contact your previous supervisor for a reference?
Yes No

May we contact your previous supervisor for a reference?
Yes No


May we contact your previous supervisor for a reference?
Yes No

Military Service

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

By marking (x) this box and clicking the submit button of this application, the applicant's signature shall constitue original signature and is legally binding for the purpose of this application. Signatures transmitted by electronic means shall be effective and binding in the same manner as original signatures.