Date: 4/18/2014

Application Form

Synergy HomeCare of Conroe

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 - Minimum Requirements

Number Question Effective Date Expiration Date
1 Are you 18 years of age or older? (required)  
     
2 Are you legally authorized to work in the United States? (required)  
     
3 Do you have a valid Texas Driver's License? (required)  
     
4 Do you have a reliable vehicle which is in good working condition that you can use without any restrictions? (required)  
     
5 Do you have valid liability insurance on your vehicle naming you as an insured driver? (required)  
     
6 Do you have reliable & consistent means of communication? (Cell phone AND E-mail) (required)  
     
7 Is your cell phone account: (required)  
 
 
8 Have you ever been convicted or charged with a felony or Class A misdemeanor? (required)  
     
9 Have you ever been charged or arrested for any crime related to theft or forgery (including check fraud, credit card abuse, shoplifting)? (required)  
     
10 If you answered "YES" to Question #8 or #9 above, please explain.  
     
11 Are you willing to consent to a thorough background check and pre-employment drug test? (required)  
     

Section 2 - Experience

Number Question Effective Date Expiration Date
1 Do you have previous experience caring for seniors or disabled persons? (required)  
     
2 How many months / years of caregiving experience do you have? (required)  
 
 
 
 
3 Was your prior experience private duty care or for an agency / facility? (required)  
 
 
 
4 Can you provide verifiable references for this experience? (Names, telephone numbers, etc.) (required)  
     
5 Please check any licenses or certifications you currently hold.  
 
 
 
 
 
6 Have you ever applied at Synergy HomeCare? (required)  
     
7 Have you ever worked for Synergy HomeCare? (required)  
     
8 Please indicate which Synergy HomeCare office you have applied at / worked for:  
 
 
 
 
 
9 Please give a brief description of previous caregiving duties you have performed: (required)  
 

Section 3 - Skills (Please check all you have experience in)

Number Question Effective Date Expiration Date
1 Alzheimer's / Dementia Care: (required)  
     
2 Bathing Assistance: (required)  
     
3 Dressing Assistance: (required)  
     
4 Transfers / Mobility Assistance: (required)  
     
5 Incontinence Care: (required)  
     
6 Gait Belt: (required)  
     
7 Hoyer Lift: (required)  
     
8 Transportation / Errands: (required)  
     
9 Light Housekeeping: (required)  
     
10 Meal Planning / Cooking: (required)  
     
11 Pediatric Care: (required)  
     
12 How many months / years experience transferring individuals from bed / chair to a wheelchair / toilet (or vice versa) do you have? (required)  
     
13 Have you been trained to perform full weight bearing transfers? Can you transfer someone greater than 150 lbs.? (required)  
     
14 Can you lift 25 lbs consistently without pain, soreness or hesitation? If not, please explain. (required)  
     
15 Do you have any physical limitations or current medical conditions that would prohibit you from lifting, rolling or transferring a person or performing any other typical home care task? (required)  
     

Section 4 - Availability

Number Question Effective Date Expiration Date
1 Are you currently employed? (required)  
     
2 If you are employed, please advise where: (If not, please indicate N/A) (required)  
 
3 If you are not employed, please advise why: (If you are, please indicate N/A) (required)  
 
4 When are you available to begin work? (required)  
     
5 Please tell us the days & times you are available to work: (required)  
 
6 Are you available for 12-hour or 24-hour shifts? (required)  
     
7 Are you available for Live-In or 24/7 Assignments? (required)  
     
8 Are you available to work on a Saturday or Sunday? (required)  
     
9 All caregivers are REQUIRED to be on a rotating "on-call" schedule. Are you willing / able to be on-call? (required)  
     
10 Are you interviewing elsewhere? (required)  
     
11 Is there anything that would prevent you from accepting a position with Synergy HomeCare? (required)  
 
12 What is the best time and day of the week for you to come to our office for a 4-5 hour orientation? (required)  
     
13 Our pay scales are 'client specific' and range from $7.25 - $11.00 per hour. Please check "YES" to confirm you have been made aware of our pay scale. (required)  
     
14 All employees are required to adhere to a uniform dress policy and you will be required to pay a one-time $30.00 fee for your uniform. Are you financially able to do so? (required)  
     

Section 5 - Geographic Preference / Area(s) Willing to Work

Number Question Effective Date Expiration Date
1 Conroe / Montgomery / Willis: (required)  
     
2 Kingwood / Humble / Atascocita: (required)  
     
3 Oak Ridge / Shenandoah / Spring: (required)  
     
4 New Caney / Porter / Splendora / Cleveland: (required)  
     
5 Magnolia / Plantersville: (required)  
     
6 Huntsville: (required)  
     
7 Crosby / Dayton: (required)  
     
8 Livingston / Onalaska / Point Blank: (required)  
     
9 Other Area(s) not listed above:  
 

Section 6 - Qualities

Number Question Effective Date Expiration Date
1 Tell us why you want to work in the non-medical home care field: (required)  
 
2 Would you be willing to accept an emergency / fill-in assignment for a client on a short notice basis? (required)  
     
3 Give us a specific example of your dependability: (required)  
 
4 Tell us why you would be an asset to Synergy's CareTeam: (required)  
 
6 Have you ever been released from a job due to disciplinary actions or being fired? (If yes, please include explanation) (required)  
 
7 Other names or aliases under which you have been employed (Maiden name, previous marriage, etc.): (If none, please indicate N/A) (required)  
 
8 How did you learn about Synergy HomeCare? (required)  
     

Section 7 - PERSONAL References (EXCLUDING immediate relative)

Number Question Effective Date Expiration Date
1 Personal Reference #1: Please provide full name, phone number, and relationship to you: (required)  
 
2 Personal Reference #2: Please provide full name, phone number, and relationship to you: (required)  
 
3 Personal Reference #3: Please provide full name, phone number, and relationship to you: (required)  
 

Section 8 - EMPLOYMENT References

Number Question Effective Date Expiration Date
1 Employment Reference #1: Please provide name of facility / employer, full name of supervisor, phone number, dates of employment, and reason for leaving: (required)  
 
2 Employment Reference #2: Please provide name of facility / employer, full name of supervisor, phone number, dates of employment, and reason for leaving: (required)  
 
3 Employment Reference #3: Please provide name of facility / employer, full name of supervisor, phone number, dates of employment, and reason for leaving: (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.