Date: 9/03/2010

Application Form

Armistead Caregiver Services

Armistead's Mission:

Armistead supports the dignity and quality of life of elderly and disabled persons by providing non-medical personal care and other caregiver services in private homes, independent and assisted living centers, hospitals, nursing homes and other facilities. Armistead is committed to respecting the integrity, wisdom, and uniqueness of each and every client.

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 - Personal Information
Number Question Effective Date Expiration Date
1 Today's Date (required)  
  N/A N/A
2 How did you hear about this position? (required)  
  N/A N/A
3 Date Available for Work (required)  
  N/A N/A
4 Are you applying for an hourly caregiving position, or a live-in caregiver position? Live-In caregivers are required to be with clients for 3-4 days at a time. (required)  
 
 
5 Hourly Caregiver Applicants Only: Desired Hours Per Week. Caregivers are considered per diem employees and hours are not guaranteed.  
  (Numeric Answer Only) N/A N/A

Section 2 - Education
Number Question Effective Date Expiration Date
1 Name of High School (required)  
  N/A N/A
2 Did you graduate? (required)  
  N/A N/A
3 Name of College  
  N/A N/A
4 Years Attended  
  (Numeric Answer Only) N/A N/A
5 Other Certifications or Degrees (LNA, LPN, etc)  
  N/A N/A

Section 3 - Please answer all questions completely!
Number Question Effective Date Expiration Date
1 Are you at least 18 years old? (required)  
  N/A N/A
2 Do you meet all the legal requirements for employment in the United States? (required)  
  N/A N/A
3 Are you able to read and write English well enough to follow verbal and written instructions and to maintain all required records? (required)  
  N/A N/A
4 Are you able to lift at least fifty (50) pounds? (required)  
  N/A N/A
5 Do you have a reliable vehicle that could be used to transport clients if needed? (required)  
  N/A N/A
6 Describe your experience working in senior care, both personal and professional. Have you provided personal care in either instance? (required)  
 
7 How many years of experience do you have caring for seniors or people with disabilities? (required)  
  (Numeric Answer Only) N/A N/A
8 Do you presently have other Employment? (required)  
  N/A N/A
9 Name of Employer  
  N/A N/A
10 May we contact your current Supervisor?  
  N/A N/A
11 Supervisor name  
  N/A N/A
12 Supervisor's Phone number  
  N/A N/A
13 Please state the reason for leaving your last job. (required)  
 
14 Did you give notice before leaving your last job? (required)  
  N/A N/A
15 If so, how much? (required)  
  N/A N/A
16 What was the salary/hourly rate for your last or current job? (required)  
  (Numeric Answer Only) N/A N/A
17 Have you ever been fired from any job? (required)  
  N/A N/A
18 If so, please explain:  
 
19 Please list the times you are available to work. Armistead requires all caregivers to be available to work at least every other weekend. (required)  
  N/A N/A
20 Please list the times you are unavailable to work. (required)  
  N/A N/A
21 Would you be willing to do Sleeping Overnight shifts? You will be up three times or less and given a place to sleep. (required)  
  N/A N/A
22 Would you be willing to do Partially Awake Overnight Shifts? You will be permitted to nap at the client's bedside. (required)  
  N/A N/A
23 Would you be willing to do Awake Overnight Shifts? You will need to be fully awake the entire shift. (required)  
  N/A N/A
24 Would you be willing to cover shifts on short notice? (required)  
  N/A N/A
25 Armistead provides care to individuals in retirement homes, nursing homes, hospitals, and similar facilities. Would you be willing to provide one-on-one care to our clients in these facilities? (required)  
  N/A N/A
26 Are you comfortable providing personal care to both male and female clients? (required)  
  N/A N/A
27 Do you have any physical restrictions that would prevent you from lifting or transferring a client? (required)  
  N/A N/A
28 Do you mind working with clients that smoke? (required)  
  N/A N/A
29 Are you willing to prepare meals for clients according to their dietary needs? (required)  
  N/A N/A
30 Are you willing to provide basic pet care? (required)  
  N/A N/A
31 Are you willing to travel to other counties for work? (required)  
  N/A N/A
32 Counties that you are willing to work in: (required)  
  N/A N/A
33 If you are willing to drive to other counties for work, how long would the shift need to be in order for you to be willing to drive to another county?  
  (Numeric Answer Only) N/A N/A
34 Armistead requires all employees to dress neatly, maintain high person hygiene standards, and wear a nametag. Can you comply with these requirements? (required)  
  N/A N/A
35 Armistead uses a web-based scheduling program to manage caregiver schedules. Do you have access to the internet? (required)  
  N/A N/A
36 Have you ever been convicted of ANY felony or misdemeanor, including sex-related or child abuse related offenses under your current name or under any other name? (required)  
  N/A N/A
37 If yes, please explain:  
 



I certify that the facts contained in this application are true and complete to the best of my knowledge.

I understand that, if employed, falsified statements on this application will be grounds for dismissal. 

In consideration for my employment, I agree to conform to the rules and regulations of Armistead, Inc.

I acknowledge that rules may be changed, withdrawn, added or interpreted at any time, at Armistead, Inc.’s sole option and without prior notice to me. 

I authorize Armistead, Inc. to investigate all statements contained within this application. I understand that if the information provided on this application cannot be satisfactorily verified by employment reference checks, my application could be considered incomplete. 

I authorize Armistead, Inc. to contact all employers listed above as well as any and all personal and employment references I have provided. 

I give Armistead, Inc. permission to investigate any and all information concerning my previous employment history as well as any job-related information previous employers may have, personal or otherwise. I authorize any of the persons and organizations listed on this application to give Armistead, Inc. any and all information concerning my previous employment, education, and qualifications for employment.

I also authorize Armistead, Inc. to request and receive such information. I hereby release employers, schools, or individuals from all liability in responding to inquiries in connection to my application. I release Armistead, Inc. from all liability for any damage that may result from utilization of such information. 

I understand that filling out this application and participating in this interview does not constitute a job offer. I understand that, if hired, I will be subject to background checks. I understand that, if hired, unfavorable background checks may be grounds for immediate dismissal. 

I understand that due to the large number of applications Armistead, Inc. receives and the competitive nature of Armistead, Inc.’s employment process, specific reasons for employment decisions will not be released.
 

I understand that Armistead, Inc. reserves the right to revise or alter policies at any time without notice.

By clicking "Submit Application", you agree to the above terms and conditions.