Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
marcia crutcher
Created: 01/22/2020
Other names under which employment may be verified:  
Updated: February 24, 2020

Home Address
Street Address
8439 south cregier ave
Unit/Suite Number
City ST/Zip
chicago, IL 60617
Home Phone
Mobile Phone
312-868-1777
Alternate Phone
312-868-1783

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

I am able to work client who has or lives with:
Family
Yes
Hospice
Yes
Cats
No
Dogs
Yes
Smoker
No
What languages do you speak?   english
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  freedom home care

How many years have you worked as a professional caregiver?  25
What percent of your previous case work has been for an agency?  50
Please explain how you will contribute to strengthen the Water Tower Nursing team.

as a professional, The strength that i will bring to Water Tower Nursing will be Respect, Patience, Hard Work, and dedication. and also the knowledge and experience that i have learned as a care giver and also as a Nurse.

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

During the 4 years that i have worked with a client in Glenview IL, it was such a joy to work with a husband and wife who were married for 66 years.the story how the met each other, and the love they had for each other was just amazing to watch. I am so greatful i had the opportunity to work with this family and i was also there when they both passed away one day apart from the other.

Availability

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

Education

High School   Newtown
Location:   Queens, New York
Did you graduate?   Yes
Subjects Studied   

College   Truman
Location:   Chicago
Did you graduate?   No
Degree:   CNA Certificate

Other:   Americare Technical School of Nursing
Location:   Park Ridge
Did you graduate?    Yes
Degree:   Associate

Special awards you earned or courses you have taken.

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Freedom Home Care
Phone
847 433-5788
Address

1749 Green Bay Rd, Highland Park, IL, 60035

Supervisor
Patty
Job Title
Liscened Practical Nurse -
Salary or Rate of Pay
Responsibilities
work with Clients in their homes, and also go to Nursing Home Facilities, Help clients with bathing, Assist with Ambulation, Exercises, Prepare Meals. Rom Exercises. Trivia, Grooming, Assist with Toileting, and Companionship.
From
01/10/2011
To
02/05/2020
Reason for Leaving
currently employed
May we contact this employer?  Yes

Company Name
Mather Lifeways
Phone
847- 492-7400
Address

1603 orrington ave Evanston Illinois

Supervisor
Cathy
Job Title
certified nurse assistant
Salary or Rate of Pay
Responsibilities
cared for residents, heleped with Adl's , take vital signs, help with feeding, and companionship.
From
09/10/1996
To
06/20/2003
Reason for Leaving
May we contact this employer?  Yes

Company Name
addolorata villa
Phone
847 -393-8050
Address

555 Mchenry road. Wheeling

Supervisor
lucy La-kissane
Job Title
Activity assistant
Salary or Rate of Pay
Responsibilities
assist residents with Activities, such as Bingo, Accohttps://hr.watertowernursing.com/wp-content/plugins/cred-frontend-editor/vendor/toolset/toolset-common/toolset-forms/images/calendar.gifmpany residents on trips on the facility Bus. Saying the Rosary, Exercises. And Trivia.
From
01/22/2009
To
01/09/2012
Reason for Leaving
left because i had a baby
May we contact this employer?  Yes

Company Name
RCM/ Chicago Public School
Phone
773-534-1198
Address

5900 N. Nina Norwood Park IL 60631

Supervisor
Geneeve Kelly
Job Title
School Nurse
Salary or Rate of Pay
Responsibilities
Assist student with medication regimen, Assist Diabetic Student, And Assist students with first aid.
From
12/10/2018
To
01/22/2020
Reason for Leaving
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 or no explanation provided.
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
Ewa Mori
Phone
773-534-1198
Address
5900 N Nina
Relationship
secretary

Name
Sonia Cooper
Phone
773-616-8621
Address
8325 south yates
Relationship
minister

Name
Pastor bentley
Phone
847- 328-7775
Address
2101 w Dempster street Evanston
Relationship
Pastor
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.
No additional notes provided.
Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
No gaps or no explanation provided.
Additional Certifications
No additional certifications or licenses provided.

Have any of your certifications or licenses been suspended or revoked?  
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
marcia crutcher

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
February 5, 2020
This application has been submitted and can no longer be edited.