Employment Questionnaire Applicant InformationApplicant Name First Last Major Cross Streets How far are you willing to travel? 5 miles 10 miles 15 miles 20 miles 25 miles Other If other, how far? When are you available to work?Monday Tuesday Wednesday Thursday Friday Saturday Sunday Do you have a reliable vehicle available to you? Yes No Are you willing to transport individuals in your vehicle? Yes No How did you hear about TLC Services?Do you have a family or individual with whom you will be working? Yes No Name Matching PreferencesWhat ages are you willing to work with? Pre-School (Ages 2-6) School Age (6-12) Young Adult (12-18) Adult (18+) Please describe any experience you have working with any of these age groups:Do you speak any languages other than english? (please specify) Are you interested in working with multiple clients? Yes No Are you interested in having your home certified to work from home? Yes No Each client we serve has a variety of individualized needs. The information you provide below will help us as we attempt to find a good match for you. Are you willing to work with an individual who:Uses a WHEELCHAIR Yes No Maybe Uses BRACES or ASSISTIVE DEVICES Yes No Maybe HITS or SCRATCHES Yes No Maybe BITES Yes No Maybe SPITS Yes No Maybe SCREAMS Yes No Maybe PULLS HAIR Yes No Maybe WEARS INCONTINENCE BRIEFS Yes No Maybe Is TUBE FED Yes No Maybe Uses a COMMUNICATION DEVICE Yes No Maybe Has SEIZURES Yes No Maybe Please describe any experience you have working with any of these needs:Is there any other information you would like us to take into consideration:SignatureThe information I have provided will be used to find potential clients for me. I understand that schedules are set as a mutual agreement between the employee and the client (client family). I understand I am not guaranteed any specified number of compensable service hours and the the client and their family have the right to choose who provides services.Applicant Signature Date MM slash DD slash YYYY Δ
