Date: 4/24/2014

Application Form

RetireEASE Senior Services Inc.

I UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT IS "AT WILL", AND MAY BE TERMINATED BY EITHER ME OR THE EMPLOYER AT ANY TIME.  NO ONE AFFILIATED WITH THE EMPLOYER HAS MADE ANY STATEMENT THAT IS CONTRADICTORY OR INCONSISTENT WITH "AT WILL" EMPLOYMENT, NOR HAS ANYONE MADE ANY STATEMENT OR PROMISE THAT I WILL BE HIRED.  

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Office Location

Select Office Location:

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - Basic Requirements

Number Question Effective Date Expiration Date
1 Do you have a CURRENT South Carolina Driver's License (required)  
     
2 If no, do you have a driver's license from another state?  
     
3 Do you have either personal or professional experience in caregiving? (required)  
     
4 Do you have your own insured reliable car? (required)  
     
5 If no, how will you get to work?  
     
6 Have you ever been convicted of a felony/misdemeanor? (required)  
     
7 If yes, please provide details  
     
8 Have you had any traffic violations? (required)  
     
9 If yes, please explain (required)  
 
10 Do you have a cell phone with voice mail? (required)  
     
11 Do you have internet access at home? (required)  
     

Section 2 - How Did You Hear About Us?

Number Question Effective Date Expiration Date
1 Please Check All That Apply (required)  
 
 
 
 
 
2 If other, please specify how you heard about us  
     
3 Did You Receive A Card About Employment? (required)  
     
4 If yes, what is the name listed on the card?  
     

Section 3 - General

Number Question Effective Date Expiration Date
1 Date of Application (required)  
     
2 What part-time position are you applying for? (required)  
 
 
 
 
3 If other, please specify position  
     
4 What is your minimum starting hourly rate? (required)  
  (Numeric Answer Only)    
7 Do you know someone who works for us? Who (required)  
     

Section 4 - Transportation

Number Question Effective Date Expiration Date
2 What type of insurance do you have on your vehicle? (required)  
 
 
 
3 Year, Make and Model of vehicle (required)  
     

Section 5 - What is your work availability?

Number Question Effective Date Expiration Date
10 If yes, what?  
     
10 We provide client services 24/7? Is there anything that would prevent you from working weekends? (required)  
     
11 If yes, would you make yourself available to be on call one weekend per month? (required)  
     
12 Can you be called at the last minute in case of emergency? (required)  
     
13 Do you have an email address and internet access at home? (required)  
     
14 Do you have your own cell phone? (required)  
     
1a Monday (required)  
     
1b If yes, what hours  
     
2a Tuesday (required)  
     
2b If yes, what hours  
     
3a Wednesday (required)  
     
3b If yes, what hours  
     
4a Thursday (required)  
     
4b If yes, what hours  
     
5a Friday (required)  
     
5b If yes, what hours?  
     
6a Saturday (required)  
     
6b If yes, what hours?  
     
7a Sunday (required)  
     
7b If yes, what hours?  
     
8b Caregiver positions are part-time/casual. This means that hours may vary and are not guaranteed. Will this arrangement satisfy your financial requirements? (required)  
     
8c Do you plan to hold another job or look for supplemental or full-time work while working with us? (required)  
     
8d If yes, please list any other employment commitments  
     
9a What days and times are you NOT available to work? (required)  
     

Section 6 - Education

Number Question Effective Date Expiration Date
1 High School Attended (required)  
 
2 City/State and Dates Attended (required)  
     
3 Graduate? (required)  
     
4 College Attended  
     
5 City/State AND Dates Attended  
     
6 Area of Concentration (ex. business, nursing, accounting, etc)  
     
7 Special Skills or Courses?  
     
8 Highest Degree Earned  
 
 
 
 
 
9 Other  
     

Section 7 - Experience

Number Question Effective Date Expiration Date
1 Briefly discuss your experience with caring for the elderly (required)  
 
2 Why do you want to work with the elderly? (required)  
 
3 What will you like the least about working with the elderly? (required)  
 
4 What are some of your interests or hobbies? (required)  
 
5 Why do you believe you are well suited for the position you are applying for? (required)  
 

Section 8 - Work History - Please go back at least 10 years

Number Question Effective Date Expiration Date
1 May we contact your current employer? (required)  
     
2 Please List Your Most Current Employer Name and Phone Number (required)  
 
3 Dates Worked/ Beginning Month/Year; Ending Month/Year (required)  
     
4 Beg/Ending Salary (required)  
     
4 Job Title/Duties (required)  
     
5 Reason for leaving (required)  
     
6 Previous Employer (required)  
     
7 Dates worked; Beginning Month/Year - Ending Month/Year (required)  
     
8 Beg/Ending Salary (required)  
     
9 Duties (required)  
 
10 Reason for leaving (required)  
     
11 If your last two jobs consisted of less than 10 years work history; please include all other employment here (please include all relevant information) (required)  
 
12 Do you have at least 10 years work experience listed? (required)  
     
13 If no, why not?  
     

Section 9 - Indicate experience with seniors in the following?

Number Question Effective Date Expiration Date
1 Parkinson's Disease (required)  
     
2 Companionship? (required)  
     
3 Bathing/Dressing? (required)  
     
4 Grooming? (required)  
     
5 Incontinence/Toileting? (required)  
     
6 Do have experience helping with transfer assist using a gait belt or hoyer lift? (required)  
     
7 Are you comfortable helping with light housekeeping? (required)  
     
8 Laundry? (required)  
     
9 Do you have experience with meal planning for the elderly? (required)  
     
10 Grocery Shopping? (required)  
     
11 Cooking? (required)  
     
12 Do you have any experience cooking for special needs diets? (required)  
     
13 If yes, what type(s)?  
     
14 Do you have any experience with assisting a senior in and out of a vehicle? (required)  
     
15 Medication Reminders? (required)  
     
16 Do you have any experience as a Team Leader or Supervisor? (required)  
     
17 Alzheimers/Dementia (required)  
     

Section 10 - General

Number Question Effective Date Expiration Date
1 Have you ever worked in any other state other than South Carolina? (required)  
     
2 If yes, please list them.  
     
3 Have you ever been released from a job due to discipline or been fired? (required)  
     
4 If yes, why?  
     
5 Please list any reason known to you why you might not be able to perform consistently and promptly any of the job duties of the position in which you are applying. (required)  
     
7 We have strict non-smoking policies while at work. If you smoke, can you go at least four hours without a cigarette? (required)  
 
 
 

Section 11 - Professional Work References -5 Non-relatives req.

Number Question Effective Date Expiration Date
1a Below, please list work references for all of your employers that we may call. . Include Company name and phone numbers.  
 
1b Reference Name and how long have you known them? (required)  
     
1c Reference Phone Numbers (required)  
     
1d Relationship to Reference (required)  
     
2a Reference Name and How long have you known them? (required)  
     
2b Reference Phone Numbers (required)  
     
2c Relationship to Reference (required)  
     
3a Reference Name and How long have you known them? (required)  
     
3b Reference Phone Numbers (required)  
     
3c Relationship to Reference (required)  
     
4a Reference Name and How long have you known them? (required)  
     
4b Reference Phone Numbers (required)  
     
4c Relationship to Reference (required)  
     
5a Reference Name and How long have you known them? (required)  
     
5b Reference Phone Numbers (required)  
     
5c Relationship to Reference (required)  
     

Section 12 - Personal References - 3 Non-relatives required

Number Question Effective Date Expiration Date
1a Below list references that know you well and can vouch for your character. To be a qualified reference, they have had to have known you a minimum of 5 years.  
 
1b Reference Name and how long have you known them? (required)  
     
1c Reference Phone Numbers (required)  
     
1d Relationship with Reference (required)  
     
2a Reference Name and how long have you known them? (required)  
     
2b Reference Phone Numbers (required)  
     
2c Relationship with Reference (required)  
     
3a Reference Name and how long have you known them? (required)  
     
3b Reference Phone Numbers (required)  
     
3c Relationship with Reference (required)  
     



CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the employer and/or its agents, including consumer reporting bureaus, to verify any information including, 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. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.