Trinity In-Home Care Provider Application Applications not completed are not processed. First Name: Middle Initial: Last Name: Birth Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 Phone: Email Address: Current Address Street: City: State: Zip: Permanent Address Street: City: State: Zip: Education High School: Dates Attended: Degree/Major: College: Dates Attended: Degree/Major: Other: Dates Attended: Degree/Major: Employment Most Recent : Dates Employed: Position: Contact Name: Address: Phone: Prior: Dates Employed: Position: Contact Name: Address: Phone: Prior: Dates Employed: Position: Contact Name: Address: Phone: References 1. Name: Address: Phone: Relationship: 2. Name: Address: Phone: Relationship: 3. Name: Address: Phone: Relationship: Briefly describe your background, interests, and experience with individuals with disabilities or older adults. How did you learn about Trinity In-Home Care? Additional Comments: Availability How many hours per week are you willing to work? Please check your day-to-day availability. Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Morning Morning Morning Morning Morning Morning Morning Daytime Daytime Daytime Daytime Daytime Daytime Daytime Evening Evening Evening Evening Evening Evening Evening Night Night Night Night Night Night Night None None None None None None None What age group(s) would you be most comfortable working with? 0-12 13-21 22-59 60+ Were you privately hired, or do you have a client with whom you prefer to work? Yes No If so, please list the name of the client you hope to work with: Are you willing to assist with activities outside of the home, such as going to the park, grocery store, etc. Yes No Are you able to transport clients in your vehicle? Yes No Do you have a valid Driver's License Yes No If so, please list you Driver's License Number: Are you able to provide care in your home? Yes No Are you willing to fix meals and assist in feeding clients? Yes No Are you willing to provide care outside of Lawrence, such as to surrounding communities of Eudora, Baldwin, and/or Lecompton? Yes No Are you willing to assist a client with personal care needs such as bathing? Yes No Do you have a current CPR or First Aid certification? Yes No If so, please list expiration dates: Do you have the ability to provide physical assistance such as turning a client in bed, or transferring a client from a bed to a chair? Yes No Do you have any physical limitations? Yes No If so, please describe: I hereby attest that the information on this application is both complete and accurate. I give permission for Trinity In-Home Care to contact my personal and employment references.
Current Address
Permanent Address
Education
Other: Dates Attended: Degree/Major:
Employment
References
1. Name: Address: Phone: Relationship:
2. Name: Address: Phone: Relationship:
3. Name: Address: Phone: Relationship:
Additional Comments:
Availability
Please check your day-to-day availability.
What age group(s) would you be most comfortable working with?
0-12 13-21 22-59 60+
Were you privately hired, or do you have a client with whom you prefer to work? Yes No
Are you willing to assist with activities outside of the home, such as going to the park, grocery store, etc. Yes No
Are you able to transport clients in your vehicle? Yes No
Do you have a valid Driver's License Yes No
Are you able to provide care in your home? Yes No
Are you willing to fix meals and assist in feeding clients? Yes No
Are you willing to provide care outside of Lawrence, such as to surrounding communities of Eudora, Baldwin, and/or Lecompton? Yes No
Are you willing to assist a client with personal care needs such as bathing? Yes No
Do you have a current CPR or First Aid certification? Yes No
Do you have the ability to provide physical assistance such as turning a client in bed, or transferring a client from a bed to a chair? Yes No
Do you have any physical limitations? Yes No
I hereby attest that the information on this application is both complete and accurate. I give permission for Trinity In-Home Care to contact my personal and employment references.
