* = Required Information
Personal Information
Name
Address
Phone
Electronic
Date of Birth
SIN
Gender
Male Female
Language
Emergency Contact Name & Phone Number of Person to contact in the event of an emergency:
Education
Formal
Informal

(Specify)

(Specify)
Restrictions
Work Limitations
List any work limitations that you may have and briefly describe:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Availability for Work
Hours & Days Available for Work
Full-Time Part-Time Short-Notice Split Shift
Indicate Days and List Hours Available for Work:
  Sunday
  Monday
  Tuesday
  Wednesday
  Thursday
  Friday
  Saturday
Client Types and Work Duties
Types of Position(s) Preferred
Home Maker Personal Care Companion Live-In Other

Weekdays (Monday a.m. to Friday a.m.) Weekends (Friday a.m. to Monday a.m.)
Client Not Willing/Able to Work With
Dementias/Alzheimers
Smokers
Mental Retardation
Behavioral Disorders
Elderly (over 65)
Children
Other

Physical Disabilities
Pets
Females
Males
Client use of marijuana purposes
HIV Positive/Aids
Duties Not Willing/Able to Perform
Bathing
Grooming
Oral Care
Dressing
Bowel Care
Bladder Care
Feeding
Ambulation
Housekeeping
Laundry
Meal Preparation
Shopping
Transportation
Medication Reminding
Friendly Reassurance Phone Call/Home Visit
Other

Experience

Bathing/Showering
Grooming
Personal Hygiene
Dressing
Bowel Care
Bladder Care
Feeding
Ambulation
Toileting
Housekeeping
Laundry
Meal Preparation
Shopping
Transportation
Medication Reminding
Friendly Reassurance Phone Call or Home Visit
Socialization
Other

Assignment Location

Yes No
Transportation
Type
Private Vehicle Bus Bike Other

Driver's License
Transporting Clients
Abuse Investigation
Yes No

Reference Information
Work Related #1 (Last Option)
Work Related #2 (2nd Last Option)
Work Related #3 (3rd Last Option)
Personal #1

(Other than relative)
Personal #2

(Other than relative)
I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employes, references and any other individual/organizations to provide information to Joy in Services Senior Home Care Agency, LLC and I hereby release and discharge any of the above and Joy in Service Home Care Agency, LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a physical examination, if requested, and understand that failure to meet and medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test as part of the Agency's pre-employment policy.

I understand that, if hired, I may be required to provide proof that I am citizen of the United States or proof that I am currently authorized to work in the United States.
Security code