Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Aldona ( Ada ) Kokocinski
Created: 05/28/2020
Other names under which employment may be verified:  
Updated: June 12, 2020

Home Address
Street Address
3600 N. Lake Shore Dr. #1512
Unit/Suite Number
City ST/Zip
Chicago, IL 60613
Home Phone
Mobile Phone
773.418.7612
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   $20-$25
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
No
Cats
Yes
Dogs
Yes
Smoker
No
What languages do you speak?   
Do you have any caregiver training from other home services agencies?  
If yes, explain.  I'm a CNA

How many years have you worked as a professional caregiver?  0.5
What percent of your previous case work has been for an agency?  0
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I'll contribute to strengthening the Water Tower Nursing team by proving how well I work as a CNA, as well as by my dedication, responsibility and trust.

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

In 2012 a very close friend of mine got very sick. Whenever I had time I prepared food for her, changed the bedding and made sure, that she had all what she needed. One night, she called me from the hospital and said : Ada I have to eat whipped cream now. What i did, I jumped out of bed took a mixer, a bowl, whip cream and went to the hospital. When I was whipping cream with the mixer , a doctor came, laugh so hard and he said Ms Beata I'll prescribe the best medication for you. It will be a whipped cream three times a day. I'll never forget my dear friend laugh.

Availability

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

Education

High School   H.S. in Torun
Location:   Torun, Poland
Did you graduate?   Yes
Subjects Studied   General H.S. program

College   Junior College
Location:   Bydgoszcz
Did you graduate?   Yes
Degree:   Associate in Cosmetology

Other:   Junior College
Location:   Gliwice
Did you graduate?    Yes
Degree:   Associate in vocal & dance

Special awards you earned or courses you have taken.
Columbia college in Chicago - 3 sem. stage makeup ; CNA.

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
St Mary (Little Sisters of Poor)
Phone
773.935.9600
Address

2325 N. Lakewood Chicago IL

Supervisor
Job Title
CNA
Salary or Rate of Pay
Responsibilities
My responsibilities as a CNA were: transferring, bathing, dressing, walking, feeding, measure and record patient's vital signs
From
01/11/2020
To
04/10/2020
Reason for Leaving
Covid-19
May we contact this employer?  Yes

Company Name
Diane Dybsky
Phone
312.560.7915
Address
Supervisor
Job Title
organizer, assistant, caregiver
Salary or Rate of Pay
Responsibilities
When Ms Diane returned home after surgery, I helped her with shopping, laundry, preparing food, taking a shower and going to the doctor. This is exact time period ( 02.01.2020 - 03.31.2020 and 06.01.2020 - 07.01.2020 )
From
02/01/2019
To
06/02/2020
Reason for Leaving
Occasionaly whenever Ms Dybsky needs me I'm still for her.
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.
I'm a mother of three children and I can say, that I dedicated my professional life to my family. When time allowed, I did many things. I can share it during an interview.
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
Rick Kosberg
Phone
312.952.8100
Address
Relationship
neighbor

Name
Margot Urbanowicz
Phone
847.420.6997
Address
Relationship
friend

Name
Thais Gram
Phone
312.351.1323
Address
Relationship
neighbor
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

I would like to add that since I was a child I have been taught a lot of empathy and care towards people with disability. I had the only sister, who was born with cerebral palsy. My parents and I took care of her so that, despite her disability, she would feel very loved, cared for and happy. I can say that this experience rooted in me deep sensitivity and respect to people who need care.

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
I'm a mother of three children and I can say, that I dedicated my professional life to my family. When time allowed, I did many things. I can share it during an interview.
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
Aldona Kokocinski

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
June 3, 2020
This application has been submitted and can no longer be edited.