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Home
Trinity In-Home Care
About Us
Our Mission
Administrative Staff
Board of Directors
Contact Us
Annual Reports
Privacy Policy
Services
In-Home Services
Service FAQ
Rates/Funding
Employment
Jobs/Apply
Staff Resources
Donate
Events
Personal Information
Name
*
First Name
Last Name
Other Names (Ex. Nickname, Maiden name, etc.)
Date available to start
MM
DD
YYYY
Contact Phone Number
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
If referred by a current TIHC family/client, what is their name?
No
Yes
Name of referral
Desired number of hours
0-10
10-20
20-35
35+
TIHC pay range is $9.50-$10.50/hr based on certifications and/or tenure. What is your required hourly wage?
$
Years of experience in interested field
Availability
Provide specific, precise times
Sunday
*
Monday
*
Tuesday
*
Wednesday
*
Thursday
*
Friday
*
Saturday
*
Which age group(s) would you be most comfortable working with?
Ages 0-12
Ages 13-17
Ages 18-64
Ages 65+
Education
High School
*
*
Graduate?
Degree
*
College/University
Graduate?
Degree
College/University
Graduate?
Degree
RN, CNA, CMA, HHA or other Licence/Certificate
License Number
State
Expiration Date
MM
DD
YYYY
License/ Certificate
License Number
State
Expiration Date
MM
DD
YYYY
Employment/Volunteer History
list present or most recent employer first, include all employment, military and volunteer service
Employer's Name
Phone Number
(###)
###
####
Address
Supervisor's Name and Title
Employment start date
MM
DD
YYYY
Employment end date
MM
DD
YYYY
Number of hours worked a week
Nature of Duties
Reason for leaving
May we contact your present employer?
Yes
No
Employer's Name
Phone Number
(###)
###
####
Address
Supervisor's name and title
Employment start date
MM
DD
YYYY
Employment end date
MM
DD
YYYY
Number of hours worked a week
Nature of Duties
Reason for leaving
Employer's name
Phone number
(###)
###
####
Address
Supervisor's name and title
Employment start date
MM
DD
YYYY
Employment end date
MM
DD
YYYY
Number of hours worked a week
Nature of Duties
Reason for leaving
How did you hear about Trinity In-Home Care
Employee (please list below)
Lawrence Journal World (online)
Lawrence Journal World (paper)
Word of Mouth
Internet
KU
Workforce Center
Flyers/Other Publications
Other (please list below)
If employee referral or other, please list
Employment Questionnaire
Are you over 18 years of age?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
Do you have a valid Driver's License?
*
Yes
No
If so, Driver's License number:
Are you willing to provide care to clients outside of Lawrence?
*
Yes
No
If so, which areas?
Baldwin
Eudora
Lecompton
Rural areas
Are you willing to provide personal care (bathing, catheter care, changing brief)?
*
Yes
No
Are you willing to assist with keeping a client's home clean and safe (light housekeeping)?
*
Yes
No
Are you willing to provide sleeping overnight support?
*
Yes
No
Are you willing to support clients in activities (going to the library or bowling)?
*
Yes
No
Are you able and willing to provide physical assistance (lifting, transfering)?
*
Yes
No
Have you been trained on how to transfer clients?
*
Yes
No
Are you willing to go shopping for a client?
*
Yes
No
Are you willing to provide meal assistance (cooking, feeding, clean up)?
*
Yes
No
Are you willing to assist a client that has challenging behaviors (biting, hitting, yelling)?
*
Yes
No
Are you able to assist client with exercise and physically demanding activities (sports)?
*
Yes
No
Are you able to work around cigarette smoke?
*
Yes
No
Are you able to work around pets/animals?
*
Yes
No
If no, please explain:
Do you have any restrictions on the days of the week you can work?
*
Yes
No
If yes, please explain:
If offered employment, can you submit verification of your legal right to work in the United States of America?
*
Yes
No
If no, please explain:
Have you been convicted of a misdemeanor or felony? (A conviction may be relevant if job-related, but does not necessarily ban you from employment)
*
Yes
No
If yes, please explain:
Have you been convicted, tried, or accused of abuse, neglect, or exploitation in the past?
*
Yes
No
If yes, please explain:
Why did you choose to apply at Trinity In-Home Care?
*
please read and sign
I certify that the information contained in this application form is true and correct to the best of my knowledge. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer, or if I am hired, my dismissal from employment.
*
Date completed
*
MM
DD
YYYY
Equal Employment Opportunity Commission Information
This section is optional.
Date of Birth
Gender
Male
Female
Race/Ethnicity
Hispanic or Latino
White/Caucasian
Black or African American
Native Hawaiian of Other Pacific Islander
Asian
American Indian of Alaska Native
Two or More Races
Thank you for applying to Trinity In-Home Care!
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