Name *

First Name

Last Name

Date available to start

MM

DD

YYYY

Contact Phone Number *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If referred by a current TIHC family/client, what is their name?

No

Yes

Desired number of hours

0-10

10-20

20-35

35+

Which age group(s) would you be most comfortable working with?

Ages 0-12

Ages 13-17

Ages 18-64

Ages 65+

*

Graduate?

Graduate?

Graduate?

Expiration Date

MM

DD

YYYY

Expiration Date

MM

DD

YYYY

Phone Number

(###)

###

####

Employment start date

MM

DD

YYYY

Employment end date

MM

DD

YYYY

May we contact your present employer?

Yes

No

Phone Number

(###)

###

####

Employment start date

MM

DD

YYYY

Employment end date

MM

DD

YYYY

Phone number

(###)

###

####

Employment start date

MM

DD

YYYY

Employment end date

MM

DD

YYYY

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)

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

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

Do you have any restrictions on the days of the week you can work? *

Yes

No

If offered employment, can you submit verification of your legal right to work in the United States of America? *

Yes

No

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

Have you been convicted, tried, or accused of abuse, neglect, or exploitation in the past? *

Yes

No

Date completed *

MM

DD

YYYY

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