Caregiver

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Which campus are you applying for? *

Grafton, WI

Howards Grove, WI

Mount Pleasant, WI

What type of employment are you interested in? *

Please check all the apply

Full-time

Part-time

Temporary/Summer

Days

Evenings

Nights

Are you able to work on weekends and holidays? *

*Every other weekend and every other holiday are required for this role.

Yes

No

Have you ever worked for Harvest Home before? *

Yes

No

Are you under the age of 18? *

If yes, a work permit will need to be provided.

Yes

No

Are you authorized to work in the United States? *

Yes

No

Is there any type of work which your physical condition prohibits, or have you ever been advised by a doctor not to perform certain types of work? *

Yes

No

Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime, in this state or any other state? *

Yes

No

Do you have a valid driver's license? *

Yes

No

Name of Employer

First Name

Last Name

Phone Number

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

May we contact this employer?

Yes

No

Name of Employer

First Name

Last Name

Phone Number

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

May we contact this employer?

Yes

No

Did you graduate? *

Yes

No

Date of Graduation

MM

DD

YYYY

Did you graduate?

Yes

No

Date of Graduation

MM

DD

YYYY

Did you graduate?

Yes

No

Date of Graduation

MM

DD

YYYY

Reference #1 *

First Name

Last Name

Phone Number *

(###)

###

####

Reference #2 *

First Name

Last Name

Phone Number *

(###)

###

####

Reference #3 *

First Name

Last Name

Phone Number *

(###)

###

####

Application Submission *

By signing and submitting this application, you are therefore agreeing to the following terms: I certify that all of the statements made by me on this application and in any interview are true, correct and complete to the best of my knowledge. I hereby grant permission to the Community and its personnel to confirm by personal inquiry or otherwise the information I give in the employment process. I understand that any willful misrepresentation or omission of facts given in the process is grounds for rejection of this application and dismissal if employed. I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I authorize the Community to release to any person, firm, entity, or organization with which I may seek employment in the future, any truthful information concerning my work experience with the Community. I hereby release and hold the Community harmless from any claim for releasing any truthful information within its knowledge and/or records. I understand that any job offer extended to me will be contingent upon the successful completion of any required criminal record check. I further understand that, if hired, my employment is for no definite period of time and that either the Company or myself may terminate our relationship at will at any time, without notice or any reason, and that this employment application does not constitute an employment contract.

First Name

Last Name

Today's Date *

MM

DD

YYYY