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Date available for work:
Rate of pay expected:
Are you 21 years of age:
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Valid Driver’s License:
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Are you legally authorized to work in the United States and have documentation verifying that authority?
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No
Applying Position:
Direct Care Worker
Habilitation Manger
Administrative
Referral Source:
Seeking Full-Time, 40HRS per week and Open to All Shifts:
Seeking Part- Time less than 30 HRS per week, Specific Days and Hours:
Have you ever worked for or with someone who is disabled:
*
Yes
No
Circle which term you like best:
Disabled
Handicap
IF you saw someone in a wheelchair and they dropped something on the ground, would you:
A. Pick it up and give it to them
B. Ask them if they need help
C. Looked at them and wait until they ask for your assistance
Have you ever been sanctioned by the Department of Health and Human Services with regard to the Medicare/Medicaid program, Central background check, or any other federal program?
Yes
No
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