Balanced Home Care

Independence, Dignity and Peace of Mind

Submit a Caregiver Application

Thank you for your interest in working as a Care Giving Partner for Balanced Home Care. Please complete the application below and hit the submit button. We will be in touch with you shortly.

NOTE: All applicants will be subject to drug testing and undergo a thorough background check.

Personal Information

PLEASE COMPLETE ALL QUESTIONS * marked fields are required
*Last Name	*First Name
Middle Name

*Address	*City
*State	*Zip Code
*How long at this address?

*Home Phone	Business Phone
Cell Phone	*Email address

Please list age (if under 18)

Employment Preferences and Background

Please indicate the days and times you are available to work:
Work anytime?	Sunday (From - To)
Monday (From - To)	Tuesday (From - To)
Wednesday (From - To)	Thursday (From - To)
Friday (From - To)	Saturday (From - To)

Position applied for:	Applied here before?
*How many hours can you work weekly?
*Are you available to work nights?
*Are you available to work weekends?
*Would you consider live-in?
*Employment desired
*Are you legally authorized to work in this country?
*When are you available to start work?
*Where did you hear about us?

Education Information

High School
Name of School	City	State
Years Completed	Degree	Major

College
Name of School	City	State
Years Completed	Degree	Major

Business / Trade School
Name of School	City	State
Years Completed	Degree	Major

Professional School
Name of School	City	State
Years Completed	Degree	Major

Criminal History

*Have you ever been convicted of a crime?
If YES, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation:
*Have you ever worked under a different name?
If YES, what was it and what was the reason?

Family and Emergency Contact

*Do you have any relatives or friends that work for Balanced Home Care?
If YES, what is their name?

In case of emergency please contact:
*Name	*Relation
*Phone	Business Phone

Driving Information

*Do you have a driver's license?
*Do you have auto insurance?
*Do you have a car?
If NO, how would you get to work?
*Have you had any accidents during the past 3 years?
If yes, how many?
*Have you had any moving violations during the past 3 years?
If yes, how many?

Personal Reference Information List two personal references. DO NOT LIST relatives or previous supervisors.

*Name	*Name
Relation	Relation
*Company	*Company
Address	Address

City	City
State	State
Zip Code	Zip Code
*Telephone (9 am - 5 pm)	*Telephone (9 am - 5 pm)

Personal Statement

An application form sometimes makes it difficult to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications to be a caregiver. Please note any experience with caregiving professionally, for your parents, spouse, children or friends.
*Why do you enjoy caregiving?
*Please describe some of your volunteer work.

Please check any certifications you currently possess:
Certified Nursing Assistant	Certified Medical Technician
Certified Medicine Aide	CPR Certified
Geriatric Nursing Assistant	First Aid Certification
Certified Home Health Aide	Personal Support Worker

Work Experience

Please list at least two of your work experiences for the past five years beginning with your most recent job held. If you were self-employed, give company name.

Current or Most Recent Employer
*Employer Name	City
*Name of last supervisor	*Phone number
Address	State/Province
Zip/Postal Code	*Your last job title
Employment Dates
From
To
Pay or Salary
*Start	*Final
*Reason for leaving (be specific):
*List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
*May we contact your employer?
If NO, Please Explain Why and Please Provide Us With Another Work Reference:

Previous Employer
*Employer Name	City
*Name of last supervisor	*Phone number
Address	State/Province
Zip/Postal Code	*Your last job title
Employment Dates
From
To
Pay or Salary
*Start	*Final
*Reason for leaving (be specific):
*List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
*May we contact your employer?
If NO, Please Explain Why and Please Provide Us With Another Work Reference:

Skill Information

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

Companionship	Dressing/Grooming
Meal Preparation	Transferring
Light Housekeeping	Incontinence Care
Bathing/Showering	Dementia/Alzheimer's Care

Comments

Balanced Home Care

In-home Care 248-528-2600

Independence, Dignity and Peace of Mind

Submit a Caregiver Application

Call us today 248-528-2600