Date: 8/23/2014

Application Form

Synergy HomeCare of Broomfield

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 * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - Willingness to Perform Client Services

Number Question Effective Date Expiration Date
1 Are you willing to provide Companionship services, including social interaction, emotional reassurance, encouragement of reading/writing, accompaniment during shopping / medical appointments / other errands or excursions? (required)  
     
2 Are you willing to provide Homemaking services, including cooking/meal prep, dishwashing, cleaning bathrooms and kitchens, laundry, changing linens, making beds, emptying trash, vacuuming, mopping, dusting, and other household chores? (required)  
     
3 Are you willing to provide Mobility assistance, including walking/ambulation, transfers, positioning, and/or encouragement of exercise? (required)  
     
4 Are you willing to provide Feeding assistance for clients who can be positioned upright and are able to independently chew and swallow without difficulty? (required)  
     
5 Are you willing to provide Medication assistance, limited to reminding/inquiring about medications, and handing appropriately marked med minders to clients? (required)  
     
6 Are you willing to provide Bathing and Grooming assistance, including showers/tub baths/bed baths, hair care, mouth care, nail care, shaving, dressing/undressing, and applying non-medicated lotions? (required)  
     
7 Are you willing to provide Toileting assistance, including emptying bedpans/urinals/commodes, changing incontinence pads/clothing, emptying catheter and/or ostomy bags? (required)  
     
8 Are you willing to provide care for clients with Alzheimer's/Dementia, including wandering prevention and protective oversight? (required)  
     
9 Are you willing to provide care for infants, toddlers and young children? (required)  
     
10 Are you willing to provide care for special needs individuals, both children and adults? (required)  
     
11 Why do you like being or want to become a caregiver for Synergy? (required)  
 
12 Describe a situation in work history where you "made the difference" in creating a positive outcome. (required)  
 

Section 2 - General Information

Number Question Effective Date Expiration Date
1 Are you a U.S. citizen? (required)  
     
2 If you are not a U.S. citizen, please indicate VISA type and number:  
     
3 Are you authorized to work in the U.S.? (required)  
 
 
 
 
4 How did you learn about Synergy HomeCare? (required)  
 
 
 
 
 
5 Have you ever applied and/or worked at Synergy HomeCare? (required)  
     
6 Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
7 If yes, please explain:  
     
8 Would you consent to a drug screening? (required)  
     

Section 3 - Education

Number Question Effective Date Expiration Date
1. Name of High School: (required)  
     
2. Location of High School: (required)  
     
3. Did you graduate? (required)  
     
4. Years Attended (From/To): (required)  
     
5. Additional Education (vocational, undergraduate, etc.)  
     
6. If yes, please list the name of the school and years attended (From/To)  
 

Section 4 - Availability

Number Question Effective Date Expiration Date
1 Date available for work? (required)  
     
2 How many hours are you willing to work each week? (required)  
     
3 Are you available to work on weekends? (required)  
     
4 Are you available to work nights? (required)  
     
5 Can you provide documentation of a driver's license and auto insurance? (required)  
     
6 Drivers License Expiration Date:  
     
7 Auto Insurance Expiration Date:  
     

Section 5 - Other Training: Certifications/Licenses/Skills

Number Question Effective Date Expiration Date
2 Are you multi-lingual?  
     
3 If yes, what languages do you speak?  
     
4 List any experience you may have had working with infants, toddlers or young children.  
 
1. Certifications/Licenses:  
 

Section 6 - Current Employment

Number Question Effective Date Expiration Date
1. Current Employer: (required)  
     
2. Address: (required)  
     
3. City: (required)  
     
4. State: (required)  
     
5. Zip Code: (required)  
     
6. Start Date: (required)  
     
7. End Date: (required)  
     
8. Hours Worked: (required)  
 
 
 
9. Position/Title: (required)  
     
10. Describe Your Responsibilities:  
 
11. Supervisor's Name/Title:  
     
11. Supervisor's Phone:  
     
13. Reason for Leaving: (required)  
 
14. May we contact? (required)  
     

Section 7 - Employment History

Number Question Effective Date Expiration Date
1. Last Employer: (required)  
     
2. Address: (required)  
     
3. City: (required)  
     
4. State: (required)  
     
5. Zip Code: (required)  
     
6. Start Date: (required)  
     
7. End Date: (required)  
     
8. Hours Worked: (required)  
 
 
 
9. Position/Title: (required)  
     
10. Describe Your Responsibilities:  
 
11. Supervisor's Name/Title:  
     
12. Supervisor's Phone:  
     
13. Reason for Leaving: (required)  
 
14. May we contact? (required)  
     

Section 8 - Professional Reference 1

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Company: (required)  
     
3. Phone: (required)  
     

Section 9 - Professional Reference 2

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Company: (required)  
     
3. Phone: (required)  
     

Section 10 - Emergency Contact Information

Number Question Effective Date Expiration Date
1. First Name: (required)  
     
2. Last Name: (required)  
     
3. Address:  
     
4. City:  
     
5. State:  
     
6. Zip Code:  
     
7. Phone 1: (required)  
     
8. Phone 2:  
     
9. Relationship: (required)  
     



I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.