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Healing Hands Homecare and Counseling Services
3159 Fee Fee Rd Ste 205
Bridgeton, MO 63044
Join Our Team
Personal Information
First Name
*
Last Name
*
Social Security Number
*
Date Of Birth MM/DD/YYYY
*
Address 1
*
Address 2
City
*
State
*
Zip Code
*
Phone
*
Email Address
*
Email:
*
What position are you applying for?
*
Office Assistant
Caregiver
Status Applying For
*
Fulltime
Partime
Are you legally authorized to work in the United States?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Consent to background check
*
Yes
No
If No, please explain.
Are you able to meet the physical and mental demands required to perform specific tasks required to perform the Consumer?
*
Yes
No
Are you emotionally mature, dependable and able to handle emergency situations?
*
Yes
No
Are you at least 18 years of age?
*
Yes
No
Are you the Consumer's spouse?
*
Yes
No
You are emotionally mature and dependable?
*
Yes
No
Do you smoke?
*
Yes
No
Have you lived in Missouri for the past 5 years? If No, what state did you live in?
*
Do you agree to maintain confidentiality?
*
Yes
No
Do you consent to a drug screening?
*
Yes
No
Is there any reason you would not be able to perform the duties of your Job?
*
How did you learn of this position?
*
Have you been charged with an offense other than a minor traffic violation?
*
Yes
No
Are you registered with the Family care safety registry?
*
Yes
No
Have you worked with persons with physical or Cognitive disabilities?
*
Yes
No
Have you applied for a Good Cause Waiver?
*
Yes
No
If Yes, When?
*
Do you have a valid driver's license?
*
Yes
No
Do you have transportation and auto insurance?
*
Yes
No
Availability
Days Available
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Do you prefer working with males, females or either?
*
Male
Female
Either
Please check the following duties that you are willing and able to perform on a daily basis:
*
Dressing
Laundry
Showering
Cleaning
Feeding
Transfers
Toilet Routine
Meal Preparation
Errands
Shopping
Homework
Correspondence
Shift preference:
*
Days
Live In
Overnight
Evenings
Any
Employment History
Employer 1
Company Name
Address
Phone
Start Date
+
End Date
+
Position
Salary
Supervisor/Manager
Reason for Leaving
May we contact?
*
Yes
No
Phone Number
Employer 2
Company Name
Address
Phone
Start Date
+
End Date
+
Position
Salary
Supervisor/Manager
Reason for Leaving
May we contact?
*
Yes
No
Phone Number
Employer 3
Company Name
Address
Phone
Start Date
+
End Date
+
Position
Salary
Supervisor/Manager
Reason for Leaving
May we contact?
*
Yes
No
Phone Number
References
Reference 1
Name
Title
Email Address
Phone
Reference 2
Name
Title
Email Address
Phone
Reference 3
Name
Title
Email Address
Phone
Additional Skills
List any additional skills that you would like to mention.
Please submit a copy of your resume.
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314.833.7779
www.healinghandslife.org