Serenity At Heart LLC Application Form

Application Form

Thank you for your interest in becoming part of the Serenity at Heart team. We believe exceptional care begins with exceptional people, and we are intentional about building a team that reflects compassion, professionalism, reliability, and genuine respect for those we serve. As you complete this application, we invite you to share your experience, qualifications, and availability so we can learn more about you and determine whether your strengths align with our current opportunities. We’re excited to learn more about you and the value you could bring to Serenity at Heart. We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name *

Last Name *

Social Security Number

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

Name: (required)

Best Contact Email (required)

Best Contact Phone # (required)

Date of Birth (required)

SSN: (required)

Date Available? (required)

Job Type? (required)

Do you have reliable transportation to and from client homes? (required)

Yes No

Can you provide documentation of a driver's license?

Yes No

Driver License Expiration Date:

Auto Insurance Expiration Date:

If yes, please explain.

What position are you applying for?

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)

Yes No

Are you willing to complete background checks, drug screening, and required onboarding training? (required)

Yes No

Desired Pay Rate? (required)

Section 2 - Employment Verification

Are you a U.S. citizen? (required)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (required)

Section 3 - Screening & Availability Questions

What days and hours are you consistently available to work? (required)

Are you available to work weekends? (required)

Yes No

Are you available to work holidays if scheduled? (required)

Yes No

How many hours per week are you looking for? (required)

Are you comfortable providing personal care such as bathing, dressing, toileting, and transferring? (required)

Yes No

Are you looking for temporary work, part-time supplemental income, or a long-term position? (required)

Section 4 - Availability

Availability Time Blocks

If you have more availability to work in the time blocks above list it here:

Can you do 12 hour shifts?

Weekend Availability:

Holiday Availability:

Do you have another job, school schedule, childcare obligation, or recurring commitment that affects the availability listed above?

Yes No

If yes, explain: _________________________

Section 5 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

Yes No

Years Attended (From/To): (required)

Additional Education (vocational, undergraduate, etc.)

Yes No

If yes, please list the name of the school and years attended (From/To)

Section 6 - Other Training: Certifications/Licenses

Certifications/Licenses:

Do you currently have CPR/First Aid certification?

Yes No

Section 7 - Current Employment

Current Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

Section 8 - Employment History

Last Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

Section 9 - Reference 1

Email:

Professional Reference: (required)

Company: (required)

Phone: (required)

Section 10 - Reference 2

Email:

Professional Reference:

Company:

Phone:

Section 11 - Emergency Contact Information

First Name: (required)

Last Name: (required)

Address:

City:

State:

Zip Code:

Phone 1: (required)

Phone 2:

Relationship: (required)

Section 12 - Additional Questions

Why should we consider you for this position? (required)

What does being dependable mean to you when a client is relying on you for care? (required)

Are you comfortable working with clients with dementia, Alzheimer’s, IDD, autism, or behavioral health needs? Please explain which one (required)

Are you currently employed with another healthcare or home-care agency? (required)

Yes No

What would cause you to turn down or leave a client assignment? (required)

Are there any types of assignments you WILL NOT accept? Please explain.

How comfortable are you with completing electronic documentation before the end of each shift?

Yes No

By submitting this application, I certify that the information provided is true and complete to the best of my knowledge. I understand that false, misleading, or omitted information may result in disqualification from employment consideration or termination if hired. I understand that submitting an application does not guarantee an interview, employment, client assignment, specific schedule, or minimum number of hours. I understand that employment may be contingent upon successful completion of required screenings, credential verification, references, orientation, training, and competency requirements. By submitting this application, I acknowledge that the availability I provide is accurate and reflects the days and times I can consistently work.

Signature