* = Required Information
Personal Information






Yes No

Male Female Other

Yes No

Yes No
Yes No
Yes No



Education



Restrictions

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Availability for Work

Full-time
Part-time
Short-notice
Split Shift
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Type of Work Seeking

Home Maker
Personal Care
Companion
Live-In
Other
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

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

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

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
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
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

Yes No
Transportation
Private Vehicle Bus
Bike Other
Yes No
Yes No
Yes No
Yes No
Yes No
3 miles or 5 kilometers
6 miles or 10 kilometers
12 miles or 20 kilometers
30 miles or 50 kilometers
Abuse Investigation
Yes No
Reference Information
Work Related #1 (Last Position)

Work Related #2 (Last Position)

Work Related #3 (Last Position)

Personal #1

Personal #2

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.

Security code