DCW Employment Application - Gwen Advanced Care, LLC

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[email protected]

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DCW Employment Application

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Welcome:
You are applying for our Direct Care Worker/ Caregiver position. This is a non-medical in-home care position for our adult or child members with disabilities, mental and/or physical.
PERSONAL INFORMATION
Today's Date:*
MM slash DD slash YYYY
Name:*
First Middle Last
Current Address:*
Street Address City State / Province / Region ZIP / Postal Code
Previous Address:
Street Address City State / Province / Region ZIP / Postal Code
Home Phone:
Cell Phone:*
This field is hidden when viewing the form
Alternate Phone:
Email:*
Enter Email Confirm Email
Are you 18 years old or older?*
- Yes
- No
Date of Birth:*
MM slash DD slash YYYY
Are you authorized to work lawfully in the United States?*
- Yes
- No
What language do you speak?*
Check all that apply
- English
- Spanish
- Other
Other languages:
Type of Identification:*
- Driver's License
- ID
- Other
Other:*
Valid Driver’s License #:*
State Issued:*
Expiration Date:*
MM slash DD slash YYYY
Valid ID #:*
State Issued:*
Do you have personal transportation?*
For some adult members, it may be necessary to transport them to & from appointments, stores, etc. Not all members require transport.
- Yes
- No
How do you travel?*
Check all that apply
- Carpool
- Uber/Lyft/Taxi
- Public Transportation
- Other
Other:*
Make & Model of Vehicle:*
Year of Vehicle:*
Auto Insurance Company:
It will be necessary to provide valid insurance at time of hire.
Policy #:
Expiration Date:
MM slash DD slash YYYY
Areas you are willing to work:*
Check all that apply
- Central Phoenix
- South Phoenix
- West Phoenix
- North Phoenix
- East Valley
- West Valley
- Other
Other:*
Are you willing to travel?*
- Yes
- No
Miles?*
Are you able to perform the essential functions of the job for which you are applying with or without reasonable accommodation? (The ability to sit, stand, bend, or squat for a long period of time? The ability to push, pull or lift a minimum of 50 pounds?)*
- Yes
- No
Explanation:*
Are you at the present time injured in any way or under doctor/physical care or treatment for an injury?*
- Yes
- No
Explanation:*
Have you ever been charged as a perpetrator or appeared on any Child Abuse Registry in the last five years?*
- Yes
- No
Please Describe:*
Have you ever been charged/convicted of a felony and/or misdemeanor?*
- Yes
- No
Please Describe:*
Have you had any moving violations?*
- Yes
- No
Please Describe:*
Emergency Contact #1:*
First Last
Phone*
Phone
Emergency Contact #2:*
First Last
Phone*
Phone

AVAILABILITY:
Due to the nature of our business, no guarantee can be made of the scheduled amount of hours you are scheduled per week. The scheduled hours are based on the members' needs.
What date are you available to begin work?*
MM slash DD slash YYYY
How many hours per week are wanting to work?*
Sunday*
- Sunday
Start Time*
End Time*
Monday*
- Monday
Start Time*
End Time*
Tuesday*
- Tuesday
Start Time*
End Time*
Wednesday*
- Wednesday
Start Time*
End Time*
Thursday*
- Thursday
Start Time*
End Time*
Friday*
- Friday
Start Time*
End Time*
Saturday*
- Saturday
Start Time*
End Time*
Have you ever been employed with Gwen's Advance Care?
- Yes
- No
If yes, when?
Have you ever been employed with Arizona Department of Economic Security (DES), Division of Developmental Disabilities (DDD)?
- Yes
- No
If yes, when?
How did you hear about us? (i.e., family, friends, website, Internet, advertisement)
Please indicate the types of services you are willing to provide:*
Check all that apply. Click service for description.
- Respite
- Attendant Care
- Habilitation
Respite service provides short term care and supervision in accordance with the person’s individual support plan. The goal of the service is to provide a break for the caregiver. This service can be provided in the person’s home or community.
Attendant Care services provide necessary support in order for the person to remain in his/her own home, and/or participate in work or community activities. The goals of the service include assisting the person to have a safe and clean home, stay healthy, and have good meals.
Habilitation is self help skills taught in steps to develop more independence and confidence. Habilitation includes a variety of methods such as special development skills, behavioral intervention, sensory and motor development skills, which are all designed to maximize the functioning of persons with developmental disabilities.
Do you have a current Fingerprint Clearance Card?*
A copy of card or certificate will be needed if hired.
- Yes
- No
Are currently CPR certified?*
A copy of card or certificate will be needed if hired.
- Yes
- No
Are currently First Aid certified?*
A copy of card or certificate will be needed if hired.
- Yes
- No
Are currently Article 9 certified?*
A copy of card or certificate will be needed if hired.
- Yes
- No
Are currently Direct Care Worker certified?*
A copy of card or certificate will be needed if hired.
- Yes
- No
Are currently Prevention and Support certified?*
A copy of card or certificate will be needed if hired.
- Yes
- No
Are you currently providing services or looking to provide services to a specific DDD member?*
- Yes
- No
Is the member currently assigned to Gwen's Advance Care?*
- Yes
- No
Member's name?*
Relationship to member?*
Are you willing to provide service to a client with a pet?*
- Yes
- No
If yes, which ones? (i.e., cats, dogs, other)*
Are you willing to provide service to a client that smokes?*
- Yes
- No
What do you like most about working with individuals with disabilities?*

EDUCATION:
Position Minimum Requires a High School Diploma or GED
Minimum Certificate Received?*
- High School Diploma
- GED
- Neither of above
High School*
Name
City*
City
State*
State
Year Graduated*
Year Graduated
Trade/Tech School
Name
City
City
State
State
Trade
Trade
Certificate Received
Certificate Received
Year Graduated
Year Graduated
College/University
Name
City
City
State
State
Major
Major
Degree Received
Degree Received
Year Graduated
Year Graduated
Describe any other training or life skills you have that apply to caring for persons with disabilities:

WORK HISTORY
Please fill out all questions in this section. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.
Previous Work Experience?*
- Yes
- No
Resume Upload
Max. file size: 100 MB.
Company #1*
Name
Are you currently working for this employer?*
Are you currently working for this employer?
- Yes
- No
City*
City
State*
State
Phone Number*
Phone Number
Supervisor's Name*
Supervisor's Name
May we contact?*
May we contact?
- Yes
- No
Employment Start*
Employment Start
MM slash DD slash YYYY
Employment End*
Employment End
MM slash DD slash YYYY
Job Title*
Job Title
Salary*
Salary
Duties*
Duties
Reason for leaving*
Reason for leaving
Company #2
Name
Are you currently working for this employer?
Are you currently working for this employer?
- Yes
- No
City
City
State
State
Phone Number
Phone Number
Supervisor's Name
Supervisor's Name
May we contact?
May we contact?
- Yes
- No
Employment Start
Employment Start
MM slash DD slash YYYY
Employment End
Employment End
MM slash DD slash YYYY
Job Title
Job Title
Salary
Salary
Duties
Duties
Reason for leaving
Reason for leaving
Company #3
Name
Are you currently working for this employer?
Are you currently working for this employer?
- Yes
- No
City
City
State
State
Phone Number
Phone Number
Supervisor's Name
Supervisor's Name
May we contact?
May we contact?
- Yes
- No
Employment Start
Employment Start
MM slash DD slash YYYY
Employment End
Employment End
MM slash DD slash YYYY
Job Title
Job Title
Salary
Salary
Duties
Duties
Reason for leaving
Reason for leaving
List any work history you have relating to the services in which we provide:

REFERENCES:
Personal and/or professional (Please do not include relatives). References will be verified.
Reference Name #1*
First Last
Relationship*
Relationship
Years Known*
Years Known
Phone*
Phone
Email
Email
Reference Name #2*
First Last
Relationship*
Relationship
Years Known*
Years Known
Phone*
Phone
Email
Email
Reference Name #3*
First Last
Relationship*
Relationship
Years Known*
Years Known
Phone*
Phone
Email
Email

CERTIFICATION AND RELEASE:
I certify that I have read and understand this application form and that the answers and statements given by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in the rejection of my application or discharge at any time during my employment. I authorize the company and its agents, including consumer-reporting bureaus to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability, which might result from making such investigations. I also understand that the use of illegal substances is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal substances prior to, and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test and/or criminal background check and all company guidelines. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Gwen’s Advance Care, LLC, and myself is terminable as at-will so that both the company and I remain free to choose to end our work relationship at any time for any or for no reason. Any changes in this employment relationship must be made in writing. I also understand that due to the nature of the business, no amount of work can be guaranteed.
My signature below acknowledges that I have read, understand, and agree to the above disclosure.*
- Agree
Electronic Signature*
Date*
MM slash DD slash YYYY

E-mail Address

[email protected]

Phone

PH: (602) 595-5707
FAX: (602) 595-7147

Location

2810 S. 24th St, Suite C108
Phoenix, AZ 85034

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Careers
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