Careers Form

General Information

First Name *

Middle Name *

Last Name *

Date

Current Address *

City

State

Zip Code

How long have you lived at this address

If less than 2 years, list previous address below

Email *

Home Phone # *

Cell #

Social Security Number

Date of Birth

Driver License #

State

Expiration Date

Insurance Company

How did you head about ACN?

Do you smoke

Yes

No

Are you willing to work in a home where client (or family member) smokes

Yes

No

Do you have any allergies that might affect the client jobs referrals you can accept

Yes

No

If yes, Please describe

Are you willing to work in a home that has Cats

Yes

No

Are you willing to work in a home that has Dogs

Yes

No

Comments

Do you speak any languages other than English

Yes

No

If yes, which

Emergency Contact

Name

Relationship to you

Cell #

Home #

Address

City

Zip

WORK REFERENCES: List four most recent document work caregiving jobs (if unable to list four caregiving jobs, including other jobs that you have had in addtion to most recent caregiving jobs)

I

Company(or Client) Name

Name of person to Contact

Title or Relationships to client if private client

Phone No(s)

Address

Your Position and Duties

Date Started

Date Ended

If still working for company or client please describe current schedule

II

Company(or Client) Name

Name of person to Contact

Title or Relationships to client if private client

Phone No(s)

Address

Your Position and Duties

Date Started

Date Ended

If still working for company or client please describe current schedule

III

Company(or Client) Name

Name of person to Contact

Title or Relationships to client if private client

Phone No(s)

Address

Your Position and Duties

Date Started

Date Ended

If still working for company or client please describe current schedule

IV

Company(or Client) Name

Name of person to Contact

Title or Relationships to client if private client

Phone No(s)

Address

Your Position and Duties

Date Started

Date Ended

If still working for company or client please describe current schedule

PERSONAL REFERENCES (not a relative)

Name

Address

Phone

How do you know this person

Name

Address

Phone

How do you know this person

TYPE OF SERVICE YOU CAN PROVIDE AND HAVE EXPERIENCE WITH

Transportation in your Vehicle (License & Liability Insurance required)

Yes

No

Transportation in Clients Vehicle (License required)

Yes

No

Assist Client with Showering

Yes

No

Give Client Bed Bath

Yes

No

Change Diapers / Assist with Incontinence

Yes

No

Give Medication Reminders to Clients

Yes

No

Light Housekeeping / Household Duties

Yes

No

Ambulation, Transferring and use of equipment

Stand by Assistance (stand by to help client if necessary)

Yes

No

Moderate Assistance (client able to provide some assistance)

Yes

No

Full Transfer (client unable to provide any assistance)

Yes

No

Assist Bed Bound Client With Positioning and Turning

Yes

No

Wheel Chair Use (including transferring from/to wheelchair)

Yes

No

User of Transfer Belts/Boards

Yes

No

Use of Hoyer Lifts)

Yes

No

Do you have any physical (or any type) of limitation that we should notify your prospective clients about?

Yes

No

If yes, please describe

Types of Service You are Willing to Work for and Have Experience with

Clients with termical Illness (often under Hospice care)

Yes

No

Clients with Limited or no Mobility

Yes

No

Clients Who are Bedbound

Yes

No

Clients with Dementia or Alzheimers

Yes

No

Clients Who have had a Stroke or have Paralysis

Yes

No

Clients Who are on Oxygen

Yes

No

Clients with Diabetes

Yes

No

Other Client Experience not listed above

IMPORTANT: The questions in a section 5 and 6 are asked for you to let ACN know the types of services you are able and willing to provide and to assist ACN in making appropriate referrals.

ACN obtains job orders from clients for non-medical caregiving and domestic services only.

ACN cannot and will not refer Domestic Worker for any medical or medically related services, including but not limited to, medication administration, medication decision making, anything invasive in nature, wound care, injections or any other related service.

It is YOUR responsibility to know your own limitations and to refuse to perform any service that is not legal for you to perform, that you are not familiar with or that you do not feel is safe for you or your clients. ACN is not responsible for determining what services you should or should not perform for your clients.

Domestic Worker understands and agrees they will not provide any medical or medication service, assistance supervision, advice or other related services to any client, person or persons pursuant to any client referrals recieved from ACN

Domestic Worker Initial

CERTIFICATIONS. Provide copies of certifications you have answered "yes" to

Registered on California's Department of Social Services Home Care Aide Registry

Yes

No

Current CNA certificate(Certified Nursing Assistant)

Yes

No

Current HHA license (Home Health Aide)

Yes

No

Negative TB test within the last 12 months (Tuberculosis)

Yes

No

Cleared Fingerprints on file with the State of California (Live Scan)

Yes

No

Other certification on training

Yes

No

If yes, please give details

AVAILABILITY. Indicate you availability below. Please notify if your availability changes.

Available for LIVE-IN jobs

Yes

No

If yes, list days you are available for live-in jobs

Indicate HOURS for each day that you are available to accept job referrals

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Commens about your schedule

Areas that your available to work in (select all that apply)

Contra Costa County	Solano Country	Alameda County	Santa Clara County
Others

Please read the following paragraph carefully and then sign:

I certify that all information provided on this form is true and correct. I understand that any false or incomplete information, regardless of when discovered, may result in my not recieving client referrals from ACN. I give my permission to ACN to contact my references and for those references to release all information requested by ACN. As part of the registration process I understand an investigate background check will be completed and give my permission for ACN to conduct an investigate background check. I authorize ACN to contact local or other law enforcements agencies, companies, corporation and schools to supply any information concerning my background, including but not limited to a computer search and release them from any liability or responsibility from their doing so. A photocopy of this authorization, or a faxed original, may be accepted in place of the original of this authorization

Print Name

Signature

Date