SUPPORT WORKER APPLICATION FORM
INSTRUCTIONS: Complete all questions (pages 1-4). Print all information requested except signature. Fax completed application to (03) 6344 2558 or email to:
[email protected] Personal Information Name: Present Address:
Date:
Last:
First:
Middle:
Street:
City:
State:
Home Phone:
Business Phone:
Post Code:
Mobile Phone:
Email Address: Languages spoken other than English:
Please indicate the days and times you are available to work: Anytime Mon – From: Tue – From: Wed – From: Thur – From:
To: To: To: To:
Fri – From: Sat – From: Sun – From:
To: To: To:
Are you available to work nights? Yes Some None
Would you consider live-in?
Are you available to work weekends? Yes Some None
When are you available to start work?
How far are you willing to travel between jobs or from your home? Do you have a current police clearance?
Yes
Km
Yes
No
OR
minutes
No
Do you hold a current First Aid Certificate? Are you legally authorised to work in Australia? Yes
No
Where did you hear about us?
Education Information Education
Name of Organisation
Location(City/State)
Number of Years Completed
Awards (Certificate)
High School
College
TAFE or Polytechnic
Other
©2011 Senior Helpers Australia Updated 24/11/14 In-Home Caring Companions
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SUPPORT WORKER APPLICATION FORM
Personal Reference Information List two personal references. DO NOT LIST relatives. Name: ____________________________________ Friend Co-worker Teacher Other Current Client Former Client
Name: ____________________________________ Friend Co-worker Teacher Other Current Client Former Client
Company: _________________________________
Company: _________________________________
Address: __________________________________
Address: __________________________________
__________________________________
__________________________________
Telephone where person can be reached 9am – 5pm
Telephone where person can be reached 9am – 5pm
(_____)____________________________________
(_____)____________________________________
An application form sometimes makes it difficult to adequately summarise a complete background. Use the space below to summarise any additional information necessary to describe your full qualifications to be a support worker. Please note any experience with support work, for your parents, spouse, children or friends. Use additional sheets, if necessary.
Why do you enjoy assisting others?
Describe some of your volunteer work:
Please list any Certificates you currently possess:
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SUPPORT WORKER APPLICATION FORM
Work Experience Please list at least two of your work experiences in the past five years beginning with your most recent job held. If you were selfemployed, give company name. Attach additional sheets if necessary.
Please disregard if this information is contained in your Resume/CV. 1. Name and address of employer:
Name of last supervisor:
Employment dates:
Pay or salary:
From:
Not mandatory
To: Phone number:
Your Last Job Title:
Reason for leaving (be specific): List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact your present employer?
Yes
No
If NO, Please Explain Why and Please Provide Us With Another Work Reference:
2. Name and address of employer:
Name of last supervisor:
Employment dates:
Pay or salary:
From:
Not mandatory
To: Phone number:
Your Last Job Title:
Reason for leaving (be specific): List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact your present employer?
Yes
No
If NO, Please Explain Why and Please Provide Us With Another Work Reference:
©2011 Senior Helpers Australia Updated 24/11/14 In-Home Caring Companions
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SUPPORT WORKER APPLICATION FORM
Skill Information How would you rate yourself on your experience with the following aspects of being a support worker? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Social Support
1
2
3
4
Incontinence Care
1
2
3
4
Meal Preparation
1
2
3
4
Dementia / Alzheimer’s Care
1
2
3
4
Light Housekeeping
1
2
3
4
Disability Care
1
2
3
4
Bathing / Showering
1
2
3
4
Palliative Care
1
2
3
4
Dressing / Grooming
1
2
3
4
Transferring
1
2
3
4
Comments:
©2011 Senior Helpers Australia Updated 24/11/14 In-Home Caring Companions
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SUPPORT WORKER APPLICATION FORM
PLEASE READ CAREFULLY APPLICATION FORM WAIVER
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I authorise investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Senior Helpers permission to contact schools, previous employers (unless otherwise indicated), references and others and hereby release Senior Helpers from any liability as a result of such contact.
Signature of applicant:__________________________________________ Date: ___________________ Printed name:
__________________________________________
Senior Helpers is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, disability, or any other characteristic protected by federal, state or local laws. We assure you that your opportunity for employment with this depends solely on your qualifications.
Thank you for completing this application form and for your interest in our business. Please return this application to our office at your earliest convenience.
Level 1, 67-69 Brisbane Street LAUNCESTON TAS 72450 OR PO Box 109 MOWBRAY TAS 7248 Phone (03) 6344 2556 Fax (03) 6344 2558 Email:
[email protected]
©2011 Senior Helpers Australia Updated 24/11/14 In-Home Caring Companions
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