Employment Application – Yes To HomeCare

Employment

Be part of the premier home healthcare team at YesToHomeCare. If you are looking for the right company to grow with, look no further. Submit your application here by filling out the following forms with the necessary information, attaching your resume, and submitting the application.

All of our employees have successfully completed and passed a thorough criminal background check. Their personal client orientation includes a specialized non-medical care curriculum program exclusive but not limited to Yes to Home Care. By filling out these forms, you are consenting to have Yes To Home Care carry out a criminal background check on you.

"*" indicates required fields

Step 1 of 8

Personal Data

Email*

Enter Email Confirm Email

Last Name*

First Name*

Middle*

SSN*

Home Address*

City*

State*

Zip*

Home Phone*

Cell Phone*

DOB*

County

List other Names and/or Aliases

Name

Emergency Contact Information

Name of Emergency Contact

Relation

Emergency Telephone Number

Job Information

Position (Job Class) Applying for:

Caregiver

RN

PT

LP/VN

CNA

OT

PTA

Clerical

Other

Date Available

REFERENCES

List of professional and personal references

References 1

References 2

References 3

References 4

I understand that I must report all accidents to my immediate supervisor and to Yes to Home Care - - No MATTER HOW SLIGHT.

I also understand that I must wear all required personal protection equipment (PPE). The penalty for not wearing PPE is disciplinary action, up to and including termination.

Signature*

Consent for Drug/Alcohol Testing and Criminal Background Checks

I,

hereby consent to taking drug and alcohol screening and testing if asked. I understand that Yes to Home Care has a zero(0) tolerance for drug use or substance abuse.I understand that Yes to Home Care has a zero(0) tolerance for drug use or substance abuse.

I understand that when notified by the company I have two hour window in which to have the drug and alcohol testing completed at the facility selected by the company. I understand that not agreeing to go in the designated time frame, being late for, or not showing up at all to the drug and alcohol screening within the designated time will reflect the same as “positive” test results, and I can be terminated.

As well, I authorize the company to conduct criminal background checks, DMV checks and perform any checks on myself as may be

I authorize all tests and background check results be released to the company and understand that the results will become part of my permanent record.

Signed*

Date*

ACKNOWLEDGMENT (Please read carefully and sign)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Yes to Home Care permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Yes to Home Care with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Yes to Home Care may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Yes to Home Care , its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information. This agency will check the employee misconduct registry (EMR) maintained by DADS. As required by TAC 93.3 and Chapter 253, Texas Health and Safety Code.

In consideration of my employment and of my being considered for employment by Yes to Home Care, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Yes to Home Care or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Yes to Home Care, at any time, can constitute a contract of employment. No representative or agent of Yes to Home Care has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Yes to Home Care is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Yes to Home Care against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

Applicant Signature*

Signed*

Date*

CAPTCHA

Employment

Personal Data

List other Names and/or Aliases

Emergency Contact Information

Job Information

Work Experience/Skills

Previous Facility Types Worked: Check All That Apply -

Check the days of the week you are available to work

Certifications: Check all applicable certifications and enter expiration date:

Work Experience

Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.

Additional Information

REFERENCES

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