* = Required Information
Applicant Information
Experience
(Previous Provider Experience)
Organization Telephone Contact Person Dates Worked May We Contact Ver
Additional Professional References
(do not include family or friends)
Contact Person Telephone Position/Title Dates Known Ver
Criminal History
YesNo
Education
Colleges/Universities
Name Location Major Graduate? End Date
High School
Name Location Graduate? End Date
Availability
YesNo
Please tell us what times you are unavailable
  Mon Tue Wed Thu Fri Sat Sun
From
To
Live-Ins - Being a Live-In means several consecutive days of care where the Provider stays at the care recipient's home for the entire number of days.
YesNo
Skills and Preferences
Please check any of the following you are willing to work with
Companionship Hoyer Lift Incontinence Transfer Assist Alzheimer's/Dementia
Females Cats Bathing/Dressing Gait Belt Driving
Smoking Males Dogs

Please check all you have experience with
Hoyer Lift Incontinence Alzheimer's/Dementia Gait Belt Transfer Assist
Specialized Training
Additional Questions
YesNo
YesNo
Emergency Contact Information
Emergency Contacts
Name Relationship Cell Phone Home Phone
Certification and Release
I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize Peachtacular Home Health Care to verify any and all information contained within this application, 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 also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.
YesNo
Restrictive Covenant
I agree not to do business directly with any individual or business entity that Peachtacular Home Health Care has introduced to me or by entering into employment with such individuals or businesses.
YesNo