Apply for One-on-One Weekend Caregiving Opportunities in Prince William County

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:	One-on-One Weekend Caregiving Opportunities in Prince William County
ID:	1033
Location:	Haymarket, VA
Department:	Home Care
Salary Range:	$18-$21 per hour

Resume
* Resume:	Supported formats: Word, PDF, RTF, Text, and HTML.

	- or Upload from:


Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Opt-In Confirmation
	I authorize recruiters from Incredicare to send text messages from 8778652923 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
Attachments
Cover Letter:	You can type in a Cover Letter or Copy/Paste from an existing document.

Caregiver Screening

* Do you have a valid Driver License?:

	Yes
	No

* Do you have an insured vehicle to use during your shifts?:

	Yes
	No

* Are you at least 21 years of age?:

	Yes
	No

* Are you willing to drive 20 miles if needed to a shift?:

	Yes
	No

Do you hold a heath care certificate from the state of Virginia?:

	CNA
	PCA
	HHA

Do you have a current CPR & 1st Aid card?:

	Yes
	No

* Can you lift up to 50lbs?:

	Yes
	No

* Can you speak, read and write in English?:

	Yes
	No

* Do you own and can you use a smart phone?

	Yes
	No

* How much experience do you have providing homecare?

	<1 year
	1-3 years
	4-9 years
	>10 years

* I am available for the following time slots:
Mark all that apply. These are not shifts.

* I am seeking:

* Will you be able to provide personal care/hygienic care for clients, such as showering, toileting assistance, and other hands-on care after proper training?

	Yes
	No

Background Disclosure

Sworn Disclosure Statement Please answer truthfully. A full background check will be performed upon hiring. Applicant Criminal Record Information

* Full Legal Name:
First, Middle, Last:

* Social Security Number:

* Date of Birth:

* To the Applicant:

Section 32.1-162.9 of the Code of Virginia requires that any person desiring to work at a licensed home care organization shall provide the hiring facility with a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges, whether within or outside the Commonwealth of Virginia.

The law prohibits license home care organizations from hiring any individuals convicted of a barrier crime (specified at the back page). However, applicants convicted of one misdemeanor barrier crime not involving abuse or neglect may be hired if five years has lapsed since the conviction.

Any person making a false statement on this form regarding any criminal offense shall be guilty of a Class 1 misdemeanor.

Further dissemination of the information provided on this form is prohibited other than to the Commissioner’s representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.

I agree that the information given below in this document is true and current to the best of my ability. I understand IncrediCare will require a criminal background check as part of being considered for a position within the company. I understand IncrediCare will deduct $25.00 from my second paycheck to cover this cost.

I have been charged, convicted of, or have pending charges that:

	Will disqualify me from working in a home care organization under Section 32.1-162.9 of the Code of Virginia
	Will Not disqualify me from working in a home care organization under Section 32.1-162.9 of the Code of Virginia
	Not Applicable to me I have never been convicted or charged with a crime.

* By signing you are giving IncrediCare permission to run a complete background check on or before your hiring date. (please sign "type" full name)

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

Submit

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	Monday to Friday Days
	Monday to Friday Overnights
	Monday to Friday Evenings
	Saturday Days
	Saturday Overnights
	Saturday Evenings
	Sunday Days
	Sunday Overnights
	Sunday Evenings
	Other (Please disclose this at phone screening)

	<10 hours per week
	10-20 hours per week
	20-25 hours per week
	25-30 hours per week
	30-35 hours per week
	35-40 hours per week

	American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
	Black or African American (Not Hispanic or Latino) A person having origins in any of the Black racial groups of Africa
	Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
	Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
	White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
	Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
	Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above races
	I Choose Not to Respond

	Vietnam Era Veteran A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
	Disabled Veteran 1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
	War/Campaign/Expedition Veteran A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
	Armed Forces Service Medal Veteran A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
	Recently Separated Veteran Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
	I Choose Not to Respond