Caregiver/Respite Application (Please print)

Transcription

1 52 Armstrng Rad Plymuth, MA PHONE: FAX: Caregiver/Respite Applicatin (Please print) Name Last First Middle Address Street City State Zip Hme # Cell # Address Date f applicatin: Date available t start: Referral Surce: Advertisement: (name & type) Internet: (website r ther) Friend/Relative: (name) Emplyee: (name) Walk-in Other:

2 PERSONAL DATA Are yu 18 years f age r lder? yes n If under 18, can yu furnish a wrk permit? yes n Are yu legally eligible t wrk in this cuntry? yes n (Prf f U.S. citizenship r immigratin status will be required upn emplyment.) Have yu filed an applicatin with this r any ther Arc befre? Have yu ever been emplyed at this r any ther Arc? Frm T D yu have any relatives r friends wrking fr this r any ther Arc? D yu have a valid driver s license? yes n If hired, will yu have a persnal insured vehicle available t yu (n site) t transprt Arc emplyees, cnsumers r equipment if required? yes n Respite Caregiver Applicants ONLY: Please tell us when yu are able t wrk I am available t wrk FULL TIME (30-40 hurs per week) and d nt have any restrictins n my hurs and days. Otherwise, cmplete availability in table belw. I am available t wrk PART TIME and d nt have any restrictins n my hurs and days. Otherwise, cmplete availability in table belw. Frm Sunday Mnday Tuesday Wednesday Thursday Friday Saturday T NOTE: Wrk schedules are based upn the needs f the business and may be subject t change n a weekly basis.

3 EMPLOYMENT HISTORY Prvide the fllwing infrmatin beginning with the mst recent emplyer. See resume is nt acceptable. Emplyer Emplyed frm (m/yy) T (m/yy) Address, City, State, Zip Starting Psitin Ending Psitin Reasn fr Leaving Supervisr Name, Title & Phne May we cntact? Duties Emplyer Emplyed frm (m/yy) T (m/yy) Address, City, State, Zip Starting Psitin Ending Psitin Reasn fr Leaving Supervisr Name, Title & Phne May we cntact? Duties Emplyer Emplyed frm (m/yy) T (m/yy) Address, City, State, Zip Starting Psitin Ending Psitin Reasn fr Leaving Supervisr Name, Title & Phne May we cntact? Duties Explain any perids f unemplyment fr mre than 30 days

4 REFERENCES List the name, title/relatinship, number f years acquainted and phne number fr at least three prfessinal references. Name Title/Relatinship Years Acquainted Phne Number PLEASE PROVIDE THE FOLLOWING INFORMATION: Languages spken: English Spanish Other List any ther special skills r qualificatins acquired frm previus emplyment r ther experiences that make yu feel especially qualified fr this psitin. List special accmplishments, publicatin, and awards: Why are yu interested in wrking fr the Arc f Greater Plymuth?

5 The Arc f Greater Plymuth empwers and supprts peple with disabilities and their families t belng, cntribute and thrive. Hw culd yu cntribute t this missin? It is understd and agreed that any misrepresentatin by me in this applicatin will be sufficient cause fr cancellatin f this applicatin and/r separatin frm the Emplyer s service if I have been emplyed. Furthermre, I understand that just as I am free t resign at any time, the Emplyer reserves the right t terminate my emplyment at any time, with r withut cause and withut prir ntice. I understand that n representative f the Emplyer has the authrity t make any assurances t the cntrary. The Emplyer is an equal pprtunity Emplyer. The Emplyer des nt discriminate in emplyment and n questin n this applicatin is used fr the purpse f limiting r excluding any applicant s cnsideratin fr emplyment n a basis prhibited by lcal, state r Federal law. I give the emplyer the right t investigate all references and t secure additinal infrmatin abut me, if jb related. I hereby release frm liability the emplyer and its representatives fr seeking such infrmatin and all ther persns, crpratins, r rganizatins fr furnishing such infrmatin. Signature f Applicant Date

6 CORI REQUEST FORM 52 Armstrng Rad Plymuth, MA PHONE: FAX: The Arc f Greater Plymuth has been certified by the Criminal Histry Systems Bard fr access t cnvictin and pending criminal case data. As a (prspective) emplyee/cntractr/vlunteer fr the psitin f, I understand that a criminal recrd check will be cnducted fr cnvictin and pending criminal case infrmatin nly and that it will nt necessarily disqualify me. The infrmatin belw is crrect t the best f my knwledge. (Prspective) Emplyee/Cntractr/Vlunteer Signature (PROSPECTIVE) EMPLOYEE/CONTRACTOR/VOLUNTEER INFORMATION (PLEASE PRINT) LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME OR ALIAS (IF APPLICABLE) PLACE OF BIRTH : - - DATE OF BIRTH: SOCIAL SECURITY NUMBER ID Theft Index PIN* (REQUIRED) (If applicable) MOTHER S MAIDEN NAME CURRENT & FORMER ADDRESSES SEX: HEIGHT: FT IN WEIGHT: EYE COLOR: STATE DRIVER S LICENSE NUMBER: (Include state f issue) *THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION: REQUESTED BY: (Signature f CORI Authrized Emplyee) *The CHSB Identify Theft Index PIN number is t be cmpleted by thse applicants that have been issued an Identity Theft Index PIN Number by CHSB. Certificated agencies are required t prvide all applicants the pprtunity t include this infrmatin t ensure the accuracy f the CORI request prcess. ALL CORI REQUEST FORMS THAT INCLUDE THIS FIELD ARE REQUIRED TO BE SUBMITTED TO THE CHSB VIA MAIL OR BY FAX TO

7 52 Armstrng Rad Plymuth, MA PHONE: FAX: REGISTRY OF MOTOR VEHICLES PERSONAL INFORMATION REQUEST FORM The fllwing infrmatin is needed in rder fr The Arc f Greater Plymuth t Request access t mtr vehicle driver recrd(s), including persnal infrmatin as Defined in 18 U.S.C Emplyee Name: Hme Address: City/State/Zip: Date f Birth: Driver s License #: Scial Security #: