Apply Online - Mountain Home Care

Please fill out the following information.

We are an equal-opportunity employer, dedicated to a policy of nondiscrimination in employment on any basis, including race, color, age, sex, religion, disability, medical condition, national origin or marital status.

Personal

First Name (required)

Last Name (required)

Address (required)

City (required)

State (required)

Zip / Postal code (required)

Phone (required)

Email (required)

Emergency Contact (Name)

Emergency Contact (Phone)

Allergies (cats, dogs, dust, etc.)

What type of position are you applying for?

Referred by

Newspaper Ad (Specify paper)

Workforce Services

Other (Specify)

Legal Record

Have you ever been convicted of a felony?

Have you ever been convicted of a misdemeanor?

If Yes to either, please provide details.

Transportation

Do you have dependable transportation?

Availability

How many hours would like to work per week?

Would you like overnight hourly shifts?

What times are you available to work?

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

Caregivers are asked to work at least one weekend shift per month. Are you able to do this?

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?

Employment History

Please enter the following information about your three most recent jobs, beginning with the most recent.

Company

Job Title

Employment Duration

From:

To:

Reason Left

Duties

Supervisor

Supervisor phone

Company

Job Title

Employment Duration

From:

To:

Reason Left

Duties

Supervisor

Supervisor phone

Company

Job Title

Employment Duration

From:

To:

Reason Left

Duties

Supervisor

Supervisor phone

Employment References

Please enter the following information for employment references that you would like us to contact.

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

Personal References

Please enter the following information for personal references that you would like us to contact.

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

Skills

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

What are your three greatest strengths?

Companionship

Bathing/Dressing

Grooming

Incontinence

Transfer Assist

Clean Bathrooms

Clean Kitchen

If Yes:

Laundry

Alzheimer's Experience

Driving

Vacuuming

Dusting

Dementia Experience

Bed Linen Changes

Grocery Shopping

Rate Cooking (1=poor, 5=excellent)

Medication Reminders

Lifting

Certification of 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 the company and/or its agents, including consumer reporting bureaus, to verify any information, including, but not limited to, criminal history and motor vehicle driving records. 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. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.