(PA) 610-572-2034
(DE) 302-358-2114

Application Form

Thank you for considering employment with Four Seasons Healthcare. We would like to advise you that we strive to hire the best-qualified candidate for each position. We comply with all regulatory agencies for reporting and disclosing appropriate information. Because we deal with vulnerable individuals, we are required to do a criminal background check. We are required to comply with these laws and want to take this opportunity to inform you of this.

Complete all questions on the application.

 

CONTACT INFORMATION

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phone

 

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PERSONAL INFORMATION

 

Have you ever been convicted of a misdemeanor or felony?

 

Yes

No

 

How did you hear about our agency?

 

 

In Case of Emergency, whom should we contact?

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EDUCATION

 

Are you a Certified Nursing Assistant (CNA)

Yes

No

 

Are you a Certified Home Health Aide (CHHA)

Yes

No

 

 

 

 

 

 

 

 

 

 

Certifications

 

 

 

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VEHICLE INFORMATION

 

Are you a licensed driver in PA/DE?

Yes

No

 

Do you own a dependable vehicle?

Yes

No

 

Vehicle details:

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EMPLOYMENT CRITERIA

 

Position applying for

Live-In

Part time

Full time

 

Date available to start:

 

What days and times would you like to work?

 

 

 

What days or times can you NOT work?

 

 

 

 

What areas are you willing to travel to?

 

 

New Castle County

 

 

 

Chester County

 

 

 

Delaware County

 

 

 

Montgomery County

 

 

 

Eastern Main Line

 

 

 

Western Main Line

 

 

 

If required, would you be willing to work:

 

 

Overtime shifts

Yes

No

 

 

Holidays

Yes

No

 

 

Saturdays/Sundays

Yes

No

 

 

Rotating Shifts

Yes

No

 

 

May we call you at the last minute if we have an emergency job that needs to be filled?

 

 

Yes

No

 

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EMPLOYMENT EXPERIENCE

 

Please indicate which of the following services you have performed for senior citizens or disabled adults:

 

Companionship:

Yes

No

 

 

Dressing:

Yes

No

 

 

Bathing:

Yes

No

 

 

Grooming:

Yes

No

 

 

Housekeeping/Laundry:

Yes

No

 

 

Bed Linen Changing:

Yes

No

 

 

Cooking:

Yes

No

 

 

Alzheimer's Dementia:

Yes

No

 

 

Incontinence/Toileting:

Yes

No

 

 

Grocery Shopping:

Yes

No

 

 

Driving to Appointments/Shopping:

Yes

No

 

 

Transfer Assistance:

Yes

No

 

 

Hoyer-Type Lift

Yes

No

 

 

Oxygen Equipment

Yes

No

 

 

Ostomy

Yes

No

 

 

Transfer Board

Yes

No

 

 

EMPLOYMENT HISTORY (or type n/a)

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May we contact?

Yes

No

N/A

 

 

 

 

 

 

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May we contact?

Yes

No

N/A


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Four Seasons Healthcare is an equal opportunity employer.  All employment decisions and advancement opportunities will be based on merit, qualifications and abilities.  Four Seasons Healthcare does not discriminate as respects employment opportunities or assignments on the basis of race, sex, color, national origin, religion, ancestry, creed, handicap, age, or any other characteristic protected by law.  Our policy is to make reasonable accommodations for handicapped employees.
 

 

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