Application - Better Health LLC

Step 1 of 5 - Personal Information

20%

Name*

First Middle Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone

Cell Phone*

Gender*

Male

Female

Open to Live-In Care*

Yes

Convicted of a felony?*

Yes

Vehicle Information

Vehicle Year*

Vehicle Make*

Driver's License*

Yes

Experience

Alzheimer's

Bed Bath

Cancer

Combative

Dementia

Dementia Experience

Gait Belt Experience

Glucose Monitor

Hospice

Hospice Experience

Hoyer Lift Experience

Incontinence

Parkinson's

Stroke

Have you had a TB test in the last 3 years?*

Yes

Result*

Positive

Negative

Date Available*

MM slash DD slash YYYY

Ideal Number of Hours Per Week

Expected Rate of Pay/hr*

Shift Availability

Monday*

Morning

Afternoon

Evening

Live-In

Tuesday*

Morning

Afternoon

Evening

Live-In

Wednesday*

Morning

Afternoon

Evening

Live-In

Thursday*

Morning

Afternoon

Evening

Live-In

Friday*

Morning

Afternoon

Evening

Live-In

Saturday*

Morning

Afternoon

Evening

Live-In

Sunday*

Morning

Afternoon

Evening

Live-In

Education

Location

Subject Studied

Years Attended

School Name

Degree

Location

Subject Studied

Years Attended

School Name

Degree

Reference

First Reference

Name

First

Relationship

Phone

Years Known

Second Reference

Name

First

Relationship

Phone

Years Known

Describe any personal, volunteer or work related experiences that will help you in this position:

Present/Last Employer

Employer Name

Telephone

Supervisor's Name

First

May we contact?

Yes

Address

Position Title

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Summary of Duties

Reason for Leaving

Previous Employer

Employer Name

Telephone

Supervisor's Name

First

May we contact?

Yes

Address

Position Title

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Summary of Duties

Reason for Leaving

Certify*

By signing this application, I certify this information to be true and agree to allow the above mentioned Home Care Agency to perform a criminal history background check, at their leisure, and I give permission for them to check my references.

Upload Files:*

Drop files here or

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CERTIFICATIONS, OTHER IDS and IN-SERVICES, Resume, Drivers License and W9 Form

Name

This field is for validation purposes and should be left unchanged.

Insurance Accepted: Private Pay, Medical Assistant (MA), MinnesotaCare, Waiver and Alternative Care

Vehicle Information

Experience

Shift Availability

Education

Reference

First Reference

Second Reference

Present/Last Employer

Previous Employer

Contact Info

Vehicle Information

Experience

Shift Availability

Education

Reference

First Reference

Second Reference

Present/Last Employer

Previous Employer

Contact Info

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