Beech Home Care

We are available to assist you 24-hours a day, 7 days a week

Because Home is Where the Heart is You really go above the call of duty. We appreciate all of the personal attention.

EMPLOYMENT FORM

Personal info

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Number in case of emergency:

E-Mail:

Social security number:

Date of birth:

What type of position are you applying for (Check all that apply)?

3-Day live-in: 4-Day live-in:
2-Day live-in: Hourly:

Referred by

Newspaper Ad (Specify paper):

Workforce Services:

Other (Specify):

Legal Record

Have you ever been convicted of a felony?

Yes: No:

Have you ever been convicted of a misdemeanor?

Yes: No:

If Yes to either, please provide details.

By clicking here, you authorize Sheridan Care, Inc. to complete your background check

Transportation

Do you drive?

Yes: No:

Driver's License #:

Do you have your own vehicle?

Yes: No:

Make and model of your vehicle:

Availability

How many hours would like to work per week?

Would you like a live-in situation (3 or 4 days per week)?

Yes: No:

Would you like graveyard hourly shifts?

Yes: No:

What times are you available to work?

May we call you at the last minute in case of an emergency need?

Yes: No:

Education

Degrees/Certificates:

Special Skills/Courses:

Experience

Please list any training or experience you have working with the elderly:

What would you like most about working with the elderly?

Skills
Please indicate whether you have assisted with or performed the following tasks for seniors.

Companionship:

Yes: No:

Bathing/Dressing:

Yes: No:

Bathing/Full Assist:

Yes: No:

Grooming:

Yes: No:

Incontinence:

Yes: No:

Transfer Assist:

Yes: No:

If Yes:

Min: Mod: Max:

Laundry:

Yes: No:

Alzheimer's Experience:

Yes: No:

Driving:

Yes: No:

Vacuuming:

Yes: No:

Dusting:

Yes: No:

Dementia Experience:

Yes: No:

Housekeeping:

Yes: No:

Incontinent/Full Assist:

Yes: No:

Bed Linen Changes:

Yes: No:

Grocery Shopping:

Yes: No:

Rate Cooking:

1 2 3 4 5

(1=poor, 5=excellent)

Medication Reminders:

Yes: No:

Lifting:

No Lifting
25 lbs or less
25-50 lbs

50-75 lbs
75+ lbs

References

Please list at least 3 business references with names and phone numbers:

When are you available for an interview?

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form 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 misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize Beech Home Care & Medical, Inc. and/or its agents to verify any information including, but not limited to, motor vehicle driving records, education, employment history, and criminal record history. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. As required by Beech Home Care & Medical, Inc. company policy, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

I Agree

Note: The site is secure to transmit personal data, i.e. social security #, dob, drivers license number.

» Caring companionship
» Meal planning and preparation
» Light housekeeping / laundry
» Transportation
» Flexible scheduling
» Respite for personal caregivers

Just a note to say how wonderful the service was today. I have been through quite a few home health services in the past 17 years, many inferior. Today was the perfect example of what home health personnel should be.

~ Jeannie