Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Wilma Hargrove
Created: 01/08/2020
Other names under which employment may be verified:  
Updated: January 14, 2020

Home Address
Street Address
120 East 44 Th Street Apt 1
Unit/Suite Number
City ST/Zip
Chicago, IL 60653
Home Phone
7732366702
Mobile Phone
7732366702
Alternate Phone
12247627106

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   18.00
Do you have a valid driver’s license?   Yes
Do you have access to a car? No

I am able to work client who has or lives with:
Family
Yes
Hospice
Yes
Cats
Yes
Dogs
Yes
Smoker
Yes
What languages do you speak?   
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Bright star Care

How many years have you worked as a professional caregiver?  8
What percent of your previous case work has been for an agency?  8
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I will bring eight years of experience dealing with Alzheimer's dementia and hospice patients! Bringing excellent care with activity of daily living and excellent care with clients. Having good communication with the agency as well.

Please share one or more personal or professional experiences you have had as a caregiver.

I have several experiences but here's one I can share with you guys I had a client who who I notice there was compacted while I was changing her diaper and was screaming very loud cause her stomach was hurting really bad so I rubbed her stomach intill the very large stool came out, she was really pleased with me and glad I was there!

Availability

Days   Yes
Nights   Yes
Weekdays   Yes
Weekends   No
Live-in   No
Can you travel outside the city of Chicago to work?   No

Education

High School   Tilden
Location:   Chicago
Did you graduate?   Yes
Subjects Studied   General studies

College   Dale Washington college
Location:   Chicago
Did you graduate?   Yes
Degree:   Phlebotomy technician

Other:   Samland health Care
Location:   Chicago
Did you graduate?    Yes
Degree:   Notion assisting certification

Special awards you earned or courses you have taken.
I have employee of the month awards from Bright Star and update on assignments and skill techniques certifications

Military Service

U.S. Military or Naval Service   No
Military branch and rank at discharge:   

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Life Care at home
Phone
7737525300
Address

5550 South Lakeshore drive Chicago Illinois

Supervisor
Kathy
Job Title
Caregiver
Salary or Rate of Pay
15.00
Responsibilities
Activity of daily living escort to and from doctor's appointment cooking cleaning companionship
From
03/08/2013
To
05/25/2018
Reason for Leaving
Resigned no hours available at the time
May we contact this employer?  Yes

Company Name
BrightStar care home health
Phone
13123822222
Address

Oak Park Illinois

Supervisor
Lenora
Job Title
Caregiver/ Cna
Salary or Rate of Pay
15.50
Responsibilities
Escort sitter caregiver responsible for activity of daily living cooking cleaning etc.
From
11/13/2019
To
01/08/2020
Reason for Leaving
Currently on call client pass a couple months ago
May we contact this employer?  Yes

 

REFERENCES & ACCEPTANCE

Thank you for entering your employment history in Part Two. Before proceeding, could you please explain any gaps in your work history.
No gaps
Character References
Please provide the names and contact information for three persons, not related to you, whom you have known for at least one year.
Name
Lakeya Hampton
Phone
7735172959
Address
Drexel avenue
Relationship
Co-worker/ nurse

Name
Shante Davis
Phone
7734071478
Address
5550 South Lakeshore drive
Relationship
Coworker/LifeCare home

Name
Daphne Davis
Phone
7737501528
Address
5550 South Lakeshore drive
Relationship
Nurse supervisor/Life Care at home
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

Currently updated with CPR and TB test

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
No gaps
Additional Certifications
No additional certifications or licenses provided.

Have any of your certifications or licenses been suspended or revoked?  No
If yes, explain.  
Resume Upload (optional)
No Resume Uploaded
If hired, would you be able to provide a copy of your Social Security Card?* (IDPH requirement)
Yes

I certify that the information contained in this application is true and correct to the best of my knowledge and I understand that falsification of this information is grounds for refusal to hire, or if hired, termination of my employment.

I agree that my employment is at-will and may be terminated or an offer of employment may be withdrawn by Water Tower Nursing and Home Care, Inc. (WTN) at any time, with or without notice, and for any lawful reason.

I understand that as a condition of employment and for continued employment, WTN may require periodic drug testing. I understand WTN will use the information gathered on this employment application to conduct background checking and will contact my references and agree to such references giving WTN any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise. I hereby release WTN, its shareholders, officers, directors, employees and agents from any an all liability for any damage that may result from the collection or utilization of such information in connection with evaluating my potential employment.

I understand if hired, I will be required to produce documentary evidence proving that I am currently authorized to work in the United States. I understand my continued employment is contingent upon providing proof of continuing work authorization upon expiration of any documents provided at time of hire. I understand I will have to provide a copy of my Social Security card upon hire as required by the Illinois Department of Public Health (IDPH).

I understand and agree that no representative of WTN has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to foregoing, unless it is in writing and signed by WTN’s President.

Accepted by
Wilma Hargrove

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
January 8, 2020
This application has been submitted and can no longer be edited.