Application Form

Are you 18 years old or older

Yes

Gender

Male

Female

Other

Why do you want to become an Amblecare HS caregiver?

What are your future plans in this field of work?

Are you legally authorized to work in Canada?

Yes

Language

Are you able to speak, read, and write fluently in English?

Yes

What languages do you speak?

Do you have reliable access to Internet and email?

Yes

Do you have a smartphone (apple or android device) with Internet/data, web browsing and texting capabilities?

Yes

If no,

Emergency Contact

Name & Phone Number of Person to contact in the event of an emergency:

Formal

Diploma

Certificate

Degree

Other

Informal

Do you have current First Aid Certification (State Level)

Expiry Date

Do you have current CPR?

Expiry Date

Have you taken a Food Safety course?

Work Limitations
List any work limitations that you may have and briefly describe:

Hearing

Yes

Hours & Days Available for Work

Full-time

Part-time

Short-notice

Split Shift

Day

Sunday

From

What is the maximum number of hours you will work in one day?

Type of Position(s) Preferred

Home Maker

Personal Care

Companion

Live-In

Other

How many years of experience do you have working as a caregiver? Please indicate where this experience was gain:

Have you ever worked as a live-in caregiver?

Never

Yes, for brief periods (less than 1 week at a time)

Yes, for periods of 1 week to 3 months

Yes, for periods of more than 3 months

Clients Not Willing/Able to Work With

Dementias/Alzheimer’s

Physical Disabilities

Smokers

Pets

Mental Retardation

Females

Behavioral Disorders

Males

Elderly (over 65)

Client use of marijuana for medicinal purposes

Children

HIVPositive/Aids

Other

Duties Not Willing/Able to Perform

Bathing

Housekeeping

Grooming

Laundry

Oral Care

Meal Preparation

Dressing

Shopping

Bowel Care

Transportation

Bladder Care

Medication Reminding

Feeding

Friendly Reassurance Phone Call/Home Visit

Ambulation

Other

Experience
Indicate which of the following you have experience in:

Bathing/Showering	Housekeeping
Grooming	Laundry
Personal Hygiene	Meal Preparation
Dressing	Shopping
Bowel Care	Transportation
Bladder Care	Medication Reminding
Feeding	Friendly Reassurance Phone Call or Home Visit
Ambulation	Socialization
Toileting	Other

Do you have experience caring for clients with the following conditions (check all the apply):

Psychiatric Disorders	Dementia
Hearing Impairment	Manual Transfer
Communication Problems	Alzheimer's
Parkinson's	Stroke
Catheter Care	Hospice/Palliative Care
Use of Hoyer Lift	Acquired Brain Injury (ABI)
Aggressive Behaviour	Ostomy Care
Multiple Sclerosis	Cancer
Cerebral Palsy	Aggressive Dementia
Diabetes	Insulin Administration
Mobility Impairment	Blindness
Traumatic Brain Injury (TBI)	G-Tube Feeding
Wound Care	IV Therapy
Spinal Injuries	Post-Surgery (Hip/Knee surguries)
Autism	Medication Administration
Tracheostomy	COPD

Are you certified or have you completed additional training in any of the following?

Personal Protective Equipment (PPE)	Roles & Expectations of PSWs and Observers
Respite care	N95 Mask Fit Test
Certified Nursing Assistant (CNA)	Trachea care
Pandemic awareness	Elder Abuse
Malnutrition and Feeding	G-tube Training
Falls Prevention & Body Mechanics	RN
Acquired Brain Injury (ABI)	Prostethics
Palliative Care	Chronic obstructive pulmonary disease (COPD)
Alzheimer's	Seizures/Epilepsy
Workplace Hazardous Material Information System ( WHMIS)	Dementia with aggressive behavior
Dementia Care	Infection Control
Foot Care Nurse	Montessori Training
Parkinson's	RPN
Gentle Persuasive Approach (GPA)	Stroke
LPN	UCP (unregulated care providers) medication
CPI	Food Handler Certificate
PCA	Physical Therapist
International Nurse	Ventilator

*Live-in care - where you stayed in the client’s residence for up to several days at a time while providing care service

Assignment Location
Are you restricted in the geographical location you are willing/able to work?

Yes

Type

Private Vehicle	Bus
Bike	Other

Transporting Clients
Are you willing to transport clients in your private vehicle?

Yes

Do you have adequate vehicle insurance?

Yes

Are you willing to drive a client’s vehicle?

Yes

Are you willing to escort a client in their own vehicle?

Yes

Are you willing to escort a client on public transportation?

Yes

How far are you willing to travel for work?

3 miles or 5 kilometers

6 miles or 10 kilometers

12 miles or 20 kilometers

30 miles or 50 kilometers

Have you ever been investigated for abuse, neglect or domestic violence?

Yes

Company Name

Address

Telephone No. & Email Address

Supervisor’s Name

Position Held

Length of Employment

Company Name

Address

Telephone No. & Email Address

Supervisor’s Name

Position Held

Length of Employment

Company Name

Address

Telephone No. & Email Address

Supervisor’s Name

Position Held

Length of Employment

Telephone No. & Email Address

Nature of Friendship (friend, co-worker, family etc.)

Telephone No. & Email Address

Nature of Friendship (friend, co-worker, family etc.)

I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to Amblecare Health Services and I hereby release and discharge any of the above and Amblecare Health Services from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary

I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check

I also understand that if I am hired, l will be required to provide proof of identity and legal authorization to work in accordance with Federal immigration laws and complete the required documentation in this regard.