RESPITE/YOUTH RESOURCES EMPLOYMENT APPLICATION
APPLICANT INFORMATION:
Today's Date:
MM
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DD
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Name: *
Your answer
Address:
Your answer
Primary Phone Number:
Your answer
Email Address:
Your answer
Are there other names under which you have worked or attended school? *
If yes, please list for reference checking purposes:
Your answer
EMPLOYMENT OBJECTIVE:
Position desired:
How did you learn about the position?
Your answer
Date available for employment: *
MM
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DD
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YYYY
Desired number of hours wanted to work per week: *
Your answer
Are you applying to work with a specific person?
If yes, who and what is your relationship?
Your answer
If yes, are you interested in working with additional families?
GENERAL INFORMATION:
Are you legally authorized to work in the U.S.?
(If hired, you will be required to provide proof of work authorization.)
Are you age 18 or older?
Have you ever been convicted of a felony, misdemeanor or other offense, or have any pending charges?
(Other than minor traffic offenses)
If yes, please explain the nature of the offense, date of conviction and state in which convicted:
(Note: Each circumstance will be judged in relation to time, seriousness and relationship to the job for which you are applying and will not necessarily bar you from employment.)
Your answer
FOR POSITIONS WHERE A VEHICLE IS REQUIRED:
Do you have access to a car?
Do you have a valid driver's license?
Do you need to be placed on the busline?
AVAILABILITY:
Please indicate the times you are interested in working by entering the exact times you are available to work each day.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Early Morning (before 8am)
Morning (8am-10am)
Mid-morning (10am-12pm)
Early Afternoon (12pm-2:30pm)
Afternoon (2:30pm-5:30pm)
Evenings (after 5:30pm)
Overnight
Please share any additional, relevant information regarding your availability:
Your answer
Please indicate which communities you are open to providing services in:
Please select all that apply.
Please indicate the environments you would like to provide services:
You may select more than one.
Do you have any allergies that prevent you from working in certain environments?
If yes, please explain:
Your answer
EXPERIENCE AND INTERESTS:
Do you have experience working with people who have disabilities?
Do you have experience assisting with personal care needs (feeding, bathrooming, dressing, etc)?
Do you have experience supporting challenging behaviors (hitting, kicking, biting, etc.)?
Which age group are you most interested in working with?
Please check all that apply.
Are you comfortable working with children or adults who use a wheelchair or other assistive equipment to help with mobility?
How many pounds are you safely able to lift?
Your answer
EDUCATION:
Please check all that apply.
High School
Undergrad/College
Graduate School
Additional relevant information regarding your education:
(Major, minor, relevant coursework, etc.)
Your answer
EMPLOYMENT HISTORY:
Please start with your most recent position. Please include all previous work experiences, including military service and significant volunteer activities.
Name of Employer: (If you have no prior employment history, please scroll to bottom of this page and click "next")
Your answer
Position:
Your answer
Address:
Your answer
Date of Hire:
MM
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DD
/
YYYY
Last Day Worked:
MM
/
DD
/
YYYY
Please list the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Your answer
Reason for leaving:
Your answer
Name of Supervisor:
Your answer
Phone:
Your answer
Email:
Your answer
May we contact this person as a reference?
If no, please provide us the name, contact information and relationship of another person we may contact:
Your answer
Name of Employer: (If you have no additional employers, please scroll to bottom of this page and click "next")
Your answer
Position:
Your answer
Address:
Your answer
Date of Hire:
MM
/
DD
/
YYYY
Last Date Worked:
MM
/
DD
/
YYYY
Please list the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Your answer
Reason for leaving:
Your answer
Name of Supervisor:
Your answer
Phone:
Your answer
Email:
Your answer
May we contact this person as a reference?
If no, please provide us the name, contact information and relationship of another person we may contact:
Your answer
Name of Employer: (If you have no additional employers, please scroll to bottom of this page and click "next")
Your answer
Position:
Your answer
Address:
Your answer
Date of Hire:
MM
/
DD
/
YYYY
Last Date Worked:
MM
/
DD
/
YYYY
Please list the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Your answer
Reason for leaving:
Your answer
Name of Supervisor:
Your answer
Phone:
Your answer
Email:
Your answer
May we contact this person as a reference?
If no, please provide us the name, contact information and relationship of another person we may contact:
Your answer
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