Before you go...

Shield Home Care, LLC is an independently owned and operated Home Instead® franchise 7120 I40 West Suite 134, Amarillo, Texas 79106 8064525360.

This application will be valid for 60 days. If you need further assistance for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

This application that you have completed online is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead franchise. This is not an employment contract. Please be sure that you answered all appropriate questions completely and accurately. False or misleading statements during the interview and on your application materials are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law.

I certify that I have read and understand the applicant note above and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application process may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I also understand that the use of illegal drugs is prohibited when carrying out my job responsibilities. I am willing to submit to drug screening if requested to detect the use of illegal drugs prior to and during employment, as allowed under applicable law.

I understand that this application is not a contract for employment.

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date:

Please indicate those tasks in which you have experience. For the areas that you do not have experience, please note if you are willing to learn.

Tasks	Experience Yes/No	Willing to Learn
Companionship/Conversation	* Yes   No	Willing to Learn
Meal Preparation (meals/snacks)	* Yes   No	Willing to Learn
Housekeeping (dust, vacuum, laundry)	* Yes   No	Willing to Learn
Bathing/showering Assistance	* Yes   No	Willing to Learn
Dressing Assistance	* Yes   No	Willing to Learn
Showering Assistance	* Yes   No	Willing to Learn
Medication Reminders	* Yes   No	Willing to Learn
Hospice Care	* Yes   No	Willing to Learn
Stroke Care	* Yes   No	Willing to Learn
Dementia Care	* Yes   No	Willing to Learn
Incidental Transportation & Errands	* Yes   No	Willing to Learn
Incontinence Care	* Yes   No	Willing to Learn
Personal Care Assistance (Female)	* Yes   No	Willing to Learn
Personal Care Assistance (Male)	* Yes   No	Willing to Learn
Alzheimer’s or Dementia Care	* Yes   No	Willing to Learn
Diabetes Care	* Yes   No	Willing to Learn
Hearing Impairment	* Yes   No	Willing to Learn
Transferring Assistance (Example: helping a person from chair to standing position)	* Yes   No	Willing to Learn
Ambulation Assistance (Example: Ensure a person’s stability and safety when moving)	* Yes   No	Willing to Learn
Mechanical Lift (Hoyer Lift)	* Yes   No	Willing to Learn

* How many years of experience do you have as a caregiver?