Job Application Form - In Home Elderly Care, Senior Home Care Services

Which Living Assistance Services location would you like to apply to?

LAS Location*

Please select an option from the dropdown.

Personal Information

Name:

First: Middle Initial: Last:

Address:

Street: Apartment: City: Prov.: Postal Code:

Tel:

Home:

Cell:

Other:

Cell Phone Service Provider:

Email:

Email Address:*

Are you legally entitled to work in Canada?

Yes
No

What languages do you speak?

Education

Course/Degree

School's Name

Degree Rec'd: Yes/No

Year Degree Rec'd

College/University

Course/Degree

School's Name

Degree Rec'd: Yes/No

Year Degree Rec'd

Other/Specify

Course/Degree

School's Name

Degree Rec'd: Yes/No

Year Degree Rec'd

Please check any of the following certifications you currently possess.

Expiry Date (if applicable)

CPR

First Aid

Food Safety Certificate

Other

Restrictions

Work Limitations:

Do you have a disability which will affect you ability to perform any of the functions of the Personal Support Worker Position?

Yes
No

If the above answer is "yes", then:

What functions can you not perform and what accommodations need to be made which would allow you to do the work more adequately?

Availability for Work

Hours & Days Available for Work:

Overnight
Live-In
Live-Out
Shifts less than 4 hours

Please note: Live-in care usually requires that you live in a client’s home continuously for 2-5 days at a time every week. For Live-in work please indicate which days you will accept:

Indicate Days and List Hours Available for Work for live-out and/or shift work:

Sunday

From:

To:

Monday

From:

To:

Tuesday

From:

To:

Wednesday

From:

To:

Thursday

From:

To:

Friday

From:

To:

Saturday

From:

To:

How much lead-time do you require before going out on a suddenly needed assignment?

Hours

Days

Client Types and Work Duties

Clients NOT Willing/Able to Work With:

Duties NOT Willing/Able to Perform:

Experience:

How would you rate yourself on your experience with the following aspects of caregiving?

1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience:

Bathing/Showering

Companionship

Grooming

Laundry

Medication Reminding

Meal Preparation

Dressing

Shopping

Bowel Care

Escorting & Transporting Clients

Bladder Care

Palliative Care

Feeding

Housekeeping

Ambulation

Cooking

Assignment Location:

Are you restricted in the geographical location you are willing/able to work?

Yes
No

Explain:

Transportation

Type Available

Personal Vehicle
Public Transportation
Other

Drivers:

If requested are you able to provide us with a driver's abstract?

Yes
No

Do you have any convictions under the Highway Traffic Act?

Yes
No

Criminal Background Check

Have you been convicted of a criminal offence for which a pardon has not been granted?

Yes
No

Voluntary Positions

Please describe any volunteer positions you have experience with in non-profit agencies, places of worship, hospitals or other organizations, if any.

Organization

Type of Work

From

To

Employment History & Reference Details

(Starting with the most recent job)

Employment Reference #1

Name:

Phone:

Address:

Last Position Held:

Length of Employment:

Reason for Leaving:

Employment Reference #2

Name:

Phone:

Address:

Last Position Held:

Length of Employment:

Reason for Leaving:

Employment Reference #3

Name:

Phone:

Address:

Last Position Held:

Length of Employment:

Reason for Leaving:

References

Professional Reference:

Name:

Address:

Telephone No.:

Email Address:

Reporting Relationship:

Character Reference:

Name:

Address:

Telephone No.:

Email Address:

Nature of Relationship (client, co-worker, teacher, etc.):

AUTHORIZATION TO RELEASE INFORMATION

Living Assistance Services is an equal employment opportunity employer dedicated to a policy of non-discimination in employment upon any basis, including race, color, creed, religion, age, sex, national origin, ancestry, sexual orientation, marital status, military status, or the presence of any non-job-related medical condition of handicap.

Please keep in mind that the questions contained in this application are not intended to be discriminatory based on any non-job-related information.

We want you to know that we will be checking your references as part of our hiring process. This may include contacting your former employers, as well as friends, acquantances and business associates. We may ask a series of questions about your personal background, work experience, character, education or personality.

AFTER READING THIS POLICY, PLEASE INDICATE YOUR AGREEMENT BY SIGNING IT IN THE SPACE PROVIDED:

I have read and fully understand the foregoing and voluntarily consent to allow Living Assistance Services to check my references by contacting any person whom they deem to be an appropriate reference. Questions may be asked about my personal background, work experience, personality, personal habits and education.

I (please type your name here):

Authorize my prior employer(s):

1:

2:

3:

To release any and all information relating to my employment with Living Assistance Services.

I further release and hold harmless the above mentioned employers and Living Assistance Services from any and all liability that may potentially result from the release and/or use of such information.

I understand that any information released by my prior employer will be held in strictest confidence, that it will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so involved will have the right to see the information.

*We thank all candidates for their interest in Living Assistance Services.

Please note that only those considered will be contacted for an interview.

Applicant's Signature