Employment Home ... Employment Employment Form Full Name Date of Birth Age Gender Male Female Full Address Contact Number (Home) Contact Number (Mobile) Email Address Are you an Australian Citizen? Yes No Best contact method EmailPhone Best contact time Morning (9am- 12pm) Afternoon (12pm- 5pm) Evening (5pm-8pm) Are you aware of any preexisting injury that may be affected by this work? If yes, please disclose any preexisting injury or disease. (Failure to disclose may result in the worker not entitled to work cover) Medical History Are you prepared to have a medical examination to confirm your fitness for work? Yes No Hobbies and Interests Availability Monday Morning Afternoon Evening Sleepover Active night Tuesday Morning Afternoon Evening Sleepover Active night Wednesday Morning Afternoon Evening Sleepover Active night Thursday Morning Afternoon Evening Sleepover Active night Friday Morning Afternoon Evening Sleepover Active night Saturday Morning Afternoon Evening Sleepover Active night Sunday Morning Afternoon Evening Sleepover Active night How many hours per week would you like to work? Are you happy to work shifts? (Minimum shift 3 hours) Yes No Comments Duties/ Responsibilities: The following is a list of duties/ tasks you may be asked to perform as a companion. Please indicate your ability/ willingness to perform each task Bathe Will not do Will do with training Have experience and training Shower Will not do Will do with training Have experience and training Bed Bath Will not do Will do with training Have experience and training Shaving Will not do Will do with training Have experience and training Grooming Will not do Will do with training Have experience and training Dressing Will not do Will do with training Have experience and training Exercise Will not do Will do with training Have experience and training Bowel care Will not do Will do with training Have experience and training The following is a list of duties/ tasks you may be asked to perform as a companion. Please indicate your ability/ willingness to perform each task Cooking Will not do Will do with training Have experience and training Assist cooking Will not do Will do with training Have experience and training Vacuuming Will not do Will do with training Have experience and training Sweeping Will not do Will do with training Have experience and training Dusting Will not do Will do with training Have experience and training Cleaning Kitchen Will not do Will do with training Have experience and training Cleaning Bathroom Will not do Will do with training Have experience and training Making beds Will not do Will do with training Have experience and training Washing clothes Will not do Will do with training Have experience and training Ironing clothes Will not do Will do with training Have experience and training Movies Will not do Will do with training Have experience and training Social activities Will not do Will do with training Have experience and training Comments Current work and education Current work/ Study details Qualifications/ training References Please list 1-3 professional references Reference 1 Full Name Relationship Company Reference 1 Contact Number Full Address Reference 2 Full Name Relationship Company Reference 2 Contact Number Reference 3 Full Name Relationship Company Reference 3 Contact Number Previous employment Are you currently working anywhere else? Yes No Have you worked as a support worker?* Yes No Any comments on your current work situation? ie: intention to leave, employer unaware that looking elsewhere etc. Police, working with children check, first aid level 2 certificate and drivers license All applicants must hold a current clean national police check and working with children check. Are you willing to undertake a national police check? Yes No Have it Are you willing to undertake a working with children check? Yes No Have it Are you willing to undertake a level 2 first aid certificate? Yes No Have it Have you been charged or convicted of a criminal offence in Australia or overseas? Yes No If yes, you are required by law to outline the nature and date of the offence(s), other than convictions under commonwealth law that occurred more than ten years ago. Details Do you have a current Victorian drivers license? Yes No Are you prepared to transport clients? Yes No Do you have comprehensive insurance? Yes No Details Upload resume Submit Now