Four Seasons Healthcare | Application Form

	CONTACT INFORMATION






	PERSONAL INFORMATION
	Have you ever been convicted of a misdemeanor or felony?
	Yes	No	If yes, please describe:
	How did you hear about our agency?

	In Case of Emergency, whom should we contact?





	EDUCATION
	Are you a Certified Nursing Assistant (CNA)			Yes	No
	Are you a Certified Home Health Aide (CHHA)			Yes	No




	Certifications



	VEHICLE INFORMATION
	Are you a licensed driver in PA/DE?			Yes	No
	Do you own a dependable vehicle?			Yes	No
	Vehicle details:
	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
	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)




	May we contact?		Yes	No	N/A





	May we contact?		Yes	No	N/A
	Provide any other additional information:
Non-Discrimination Policy. Four Seasons Healthcare is an equal opportunity employer and service provider. Four Seasons Healthcare does not discriminate in making employment, operational or consumer decisions on the basis of race, sex, color, national origin, religion, ancestry, creed, handicap, age, genetics or any other characteristic protected by law. Our policy is to make reasonable accommodations for both handicapped employees and consumers. All employment decisions and advancement opportunities will be based on merit, qualifications and abilities.