Compassionate Home Health Services for Durham, NC Residents

Healing Horizon Community Care

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Healing Horizon Community Care LLC - Employment Application

Healing Horizon Community Care LLC

Phone: 919-226-0292 | 1-866-357-3992
Email: [email protected]
Website: healinghorizoncommunitycare.org

Employment Application Form

Applicant Information

Full Name Address City State ZIP Phone Number Email Address Date of Birth (optional) Emergency Contact Name Emergency Contact Phone

Position Applied For

In-Home Aide (IHA) Companion / Sitter Respite Care Provider Peer Support Other

Available Start Date Preferred Work Schedule

Work Experience

Most Recent Employer Position Held Supervisor Name Supervisor Phone

Certifications & Training

CPR / First Aid CNA I CNA II NCI / Behavioral Training TB Test (current) Background Check Driver’s License Auto Insurance

Availability

Full-Time Part-Time Weekends Live-In Overnight PRN / As Needed

Days Available

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

References (Professional)

Reference 1 Name Phone Relationship Reference 2 Name Phone Relationship

Background Questions

Have you ever been convicted of a felony? If yes, explain: Are you able to lift 25+ lbs if required? Do you have any health conditions that may limit your work? If yes, explain: I certify that the information provided is true and accurate. Electronic Signature Date