Healthcare Plus Online Application

Healthcare Plus is an equal opportunity employer. All applicants will be considered without regard to race, color, religion, creed, sex (including pregnancy, childbirth, or related medical conditions), gender identity and expression, sexual orientation, genetic information, national origin, ancestry, age (40 and over), disability, citizenship status, veteran status, military status or military obligations, or any other basis protected by applicable federal, state, or local government laws. Healthcare Plus also prohibits harassment of applicants based on any applicable legally protected category. It is also Healthcare Plus policy to comply with all
deferral, state, and local government laws respecting consideration of unemployment status in making hiring decisions. Healthcare Plus maintains a smoke-free workplace in accordance with applicable law. Applicants are not obligated to disclose sealed or expunged records of convictions or arrest.

First NameMiddle NameLast Name

PhoneTabletDesktop/ LaptopOther

Street Address

Apt

City / TownState / Province

Postal / Zip Code

Please enter a valid phone number.

Confirmation Emailexample@example.com (confirm email in second box)

Please enter a valid phone number.

	Mornings	Noon	Nights
Monday
Tuesday
Wednesday
Thrusday
Friday
Saturday
Sunday

EnglishSpanishTagalogOther

Mr. / Sr.Ms. / Srta.Mrs. / Snra.Non-binary / No binario

Own CarPublic Transportation

Declination of Vaccination Checkmark

Single or Married filing seperatelyMarried filing jointly or Qualifying Widow(er)Head of Household (Check only if you're unmarried and pay more than half the cost of keeping up a home for yourself and a qualifying individual.)

Check box if Applicable

If applicable check box

A citizen of the United StatesA noncitizen national of the United StatesA lawful permanent resident(Alien Registration Number/USCIS Number):An alien authorized to work until

Commitment to Safe Driving

By signing below, I agree to the following:

● I understand that I am responsible for maintaining a safe driving record and informing Healthcare Plus of any accidents, traffic citations, or legal actions related to driving that occur during my employment.
● I commit to providing Healthcare Plus a copy of my updated Driver’s License and proof of car insurance (if applicable).
● I certify that all information provided in this questionnaire is correct and complete to the best of my knowledge.

HOME CARE AIDE TRANSPORTATION AGREEMENT

If HCA will NOT be driving, do not proceed; Complete “Do Not Drive” Waiver

A Home Care Aide (HCA) driving for Healthcare Plus (Company) clients in any vehicle must adhere to safe driving standards, including compliance with all traffic laws and DMV regulations. The use of hand-held devices for calls, texting, emailing, or browsing while driving is prohibited. HCAs may use their personal vehicles for Company business only if the vehicle is well-maintained and in safe condition. Any vehicle accident, damage, or traffic violation must be reported to both the Case Supervisor and their insurance carrier within 24 hours. HCAs must notify their insurer of business use of their vehicle and ensure the Company is not excluded from their personal insurance. HCAs are responsible for any deductibles and must carry personal vehicle insurance meeting State requirements. HCA’s insurance is primary, with Company insurance as excess coverage. The Company will not reimburse the HCA for theft, road damage, collision, or any tickets and other violations.

I agree to comply with the above policy and understand that any violation thereof may result in disciplinary action up to and including termination.

______I represent and warrant I will drive Company clients in my personal vehicle only if my vehicle is in safe operating condition and has received regular maintenance.

______I agree to carry personal vehicle insurance, covering liability and physical
damage, in amounts sufficient to satisfy any requirements under state law.

I accept the risks of driving for the Company and waive any claims against the Company for bodily injury or property damage related to such driving. I agree to indemnify, defend, and hold harmless the Company, its officers, employees, and successors from any related liability.

Welcome to Healthcare Plus Online Application

Employee Application

Refferences

Staffing Questionnaire

Policy & Procedures

Employee Handbook

W-4 Forms

Tax Withholding Estimator

IRS Worksheet

I-9 & Background

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I certify that the above is true and correct and give my consent for my name to appear on Department’s Health Care Worker Registry with the results of my criminal history records check.

Home Care Aide (HCA) Driving History Questionnaire

Driving History

Required Documents