Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Lea Pedra Del Mar
Created: 12/23/2019
Other names under which employment may be verified:  
Updated: January 2, 2020

Home Address
Street Address
5311 N Delphia Ave
Unit/Suite Number
Apt 112
City ST/Zip
Chicago, IL 60656
Home Phone
Mobile Phone
773-704-0284
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? Friend
Rate of pay desired.   $30
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
Yes
Dogs
Yes
Smoker
No
What languages do you speak?   
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Omega Healthcare Technical School (Basic Nurse Assistant Training Program)

How many years have you worked as a professional caregiver?  15
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.

I will contribute to strengthen the Water Tower Nursing team through delivering my best care to your patients, based on my extensive experience with working for all types of patients. I am passionate in what I do and have served as a caregiver for over 15 years now and want to continue to deliver the best professional and personal care I can to your patients.

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

I have recently worked as a private caregiver for the past 6.5 years, until she passed due to heart problems. I worked closely with my patient's family and friends, serving as her companion and caregiver. I took care of her overall well-being, taking care of her dementia, Alzheimer's, food preparation, showering, wound clinics, to name a few. Caring for her was a very fulfilling experience and

Availability

Days   Yes
Nights   Yes
Weekdays   Yes
Weekends   Yes
Live-in   Yes
Can you travel outside the city of Chicago to work?   Yes

Education

High School   MVS Margen Ormoc City
Location:   Ormoc City, Phillipines
Did you graduate?   Yes
Subjects Studied   

College   
Location:   
Did you graduate?   
Degree:   

Other:   
Location:   
Did you graduate?   
Degree:   

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
Lori Leavitt
Phone
8472124890
Address

711 Lee Road

Supervisor
Lori Leavitt
Job Title
Private Caregiver
Salary or Rate of Pay
$30 per hour
Responsibilities
Personal Caregiver, working around the clock assisting the patient with daily life responsibilities (ranging from giving medicine, bathing, errands, appointments, etc.)
From
04/02/2013
To
12/19/2019
Reason for Leaving
Natalie Gold, Lori's
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.
Prior to working with Natalie Gold (my most recent patient), I worked in Regency Nursing Homes.
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
Lori Leavitt
Phone
8472124890
Address
711 Lee Road
Relationship
My past/most recent client

Name
Linda Gold
Phone
8479223144
Address
711 Lee Road
Relationship
My past/most recent client

Name
Phone
Address
Relationship
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.
Prior to working with Natalie Gold (my most recent patient), I worked in Regency Nursing Homes.
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
Lea Del Mar

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted