Caregiver - Residential Support Staff

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Please complete the form below to apply for this position.

* First Name:
Middle Name:
* Last Name:
Address:
City:
State/Province:
Zip Code:
Email Address:
Phone Number:
Resume Upload:
Cover Letter Upload:
* Have you been known by any other name in the past 5 years?
Yes
No
If you answered yes, please list any previous names.:
Previous Full Address (if less than 3 years at present address):
Best way to reach you:
Phone
Email
* Are you 18 years or older?
Yes
No
Minimum age requirement for a Child Care Provider position is 21. Are you 21 years of age or older?
Yes
No
* Are you legally eligible for employment in the United States? (If offered employment, you will be required to provide documentation to verify eligibility):
Yes
No
Do you have a valid driver's license?
Yes
No
Type of employment desired:
Full Time
Part Time
Either
Date available to begin work:
Wage Desired/Expected:
EDUCATION
Highest grade completed in school:
Have you ever been employed by Agape of Appleton, Inc.?
Yes
No
If yes, please list years of employment and reason for leaving:
Name and location of High School attended:
Do you have a High School Diploma or GED Equivalency?
Yes
No
College and/or Vocational School:
Subjects studied/Major:
Degree:
College and/or Vocational School:
Subjects studied/Major:
Degree:
Describe any education or training you have which you feel is relevant to the job for which you are applying:
Are you registered with the DHFS Registry for nurse assistants, home health aides, or hospice aides?
Yes
No
Have you had experience as a caregiver, home health aide, CNA, or equivalent? If yes, please describe:
* Agape of Appleton, Inc. Policy requires each employee to have the physical and emotional capacity to adjust to problems involved in the care and supervision of persons having physical, social, or mental disabilities. Following is a partial list of essential functions of the job:
  • Provide participants with ongoing instructions in self-care and daily living skills.
  • Encourage and support participants with their social relationships and in their planning and use of their leisure time.
  • Assist participants with the upkeep of their personal living quarters.
  • Transport participants with agency vehicles or personal vehicle.
  • Transfer and lift participants according to their needs, using proper techniques to ensure the safety of all involved.
  • Be capable, both mentally and physically, to assist participants during emergency situations such as, but not limited to: evacuation of premises, physical aggressions, and assistance during epileptic seizures.
  • Monitor participant's behavior and conduct, encouraging and supporting appropriate behavior and socialization with others, and appropriately handle challenging behaviors.
Are you able to perform the essential functions of the job with or without reasonable accommodation?
(Answer only after reviewing the previous list of essential job duties. Existence of physical, medical, or emotional limitations does not automatically bar employment and your record will be considered only as it relates to the job for which you have applied):
Yes
No
WORK EXPERIENCE (List most recent first)

Employer 1:
Job Title:
Start/End Date of employment:
Reason for Leaving:
Salary/Hourly Wage at Employer 1:
May we contact Employer 1 for a reference?
Yes
No
Employer 2:
Job Title 2:
Start/End Date of Employment:
Reason for Leaving:
Salary/Hourly Wage:
May we contact Employer 2 for a reference?
Yes
No
Employer 3:
Job Title 3:
Start/End Date of Employment:
Reason for Leaving:
Salary/Hourly Wage:
May we contact employer 3 for a reference?
Yes
No
REFERENCES

List at least 2 business references.

Reference Name 1:
Phone Number (required)
 :
Email Address (required):
Relationship:
Reference Name 2:
Phone Number (required)

 :
Email Address (required):
Relationship:
Reference Name 3:
Phone Number (required)
 :
Email Address (required):
Relationship:
* How did you learn about Agape's job openings?
* AUTHORIZATION, RELEASE AND VERIFICATION

Please read the following statements carefully before you sign your name.

I HEREBY CERTIFY that the answers given by me to the above questions and statements are true and correct and hereby authorize you to contact references, past or present employers, persons, schools, law enforcement agencies and any other sources of information which may be relevant to my application for employment. These checks may include a criminal record check pursuant to the Wisconsin Fair Employment Act and, when applicable, a check with the Department of Health & Family Services Registry, as required and authorized per HFS 12.02(b) of the Department of Health & Family Services Administrative Codes and a driving record check. It is understood and agreed that any misrepresentation, false statement, or omissions by me in this application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to this Company. This includes furnishing a false name or social security number. I have read, understand and agree to the above statement.

Please initial here:
* I further understand that no representative of the Company has the authority to enter into any agreement for employment for any specified period of time and that this Company is not guaranteeing employment for anyone.  No employment contract is created by virtue of my being hired by this Company, and, if hired, my employment will be at will and may be terminated at any time without prior notice.  I have read, understand and agree to the above statement.

Please initial here:
* I understand that, if hired by this agency, I will be requested to provide identifying documents to verify authorization to work in the U.S. within the time frames specified in the law.

Should I be hired, upon my termination of employment, I authorize the release of reference information on my work history and performance.

I understand that this application will remain on file for 60 days for consideration. After 60 days, if I am still interested in a position with this Company, it will be necessary for me to complete a new application form:
I certify that I have read and understand this authorization, release, and verification.
* Please type your name and date in the boxes below. This will serve as your signature

Name:
* Date:
* Required Field

Equal Opportunity Employer
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