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Application for Respite Worker - Brandon (Westman)
Applicant Information
Name
First
Last
Address
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone
Email
Type of Employment Desired:
Part-time – More than 20 hour per week
Part-time – Less than 20 hours per week
Casual – work minimum 2 shifts per month (Westman location only)
Please specify for us the hours you ARE available to work. If employed by another employer, please specify hours available to work outside of your other employment:
Open/No Preference
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Requirements:
WE WILL NOT INTERVIEW UNLESS ALL 3 CHECKS ARE IN YOUR POSSESSION!
Do you have a clear Criminal Record Check with Vulnerable Sector Check, done within the last 3 months?
Yes
No
If yes, when?
Do you have a clear Child Abuse Registry Check, done within the last 3 months?
Yes
No
If yes, when?
Do you have a clear Adult Abuse Registry Check, done within the last 3 months?
Yes
No
If yes, when?
Are you legally entitled to work in Canada?
Yes
No
Certificates/Training:
Are you currently certified in First Aid/CPR?
Yes
No
Are you currently certified in Non Violence Crisis Intervention?
Yes
No
Do you hold a current Driver’s License?
Yes
No
Work History #1
Company
Phone
Address
Supervisor
May we contact your previous supervisor for a reference?
Yes
No
Job Title
Responsibilities
Start & End Dates
Reason for Leaving
Work History #2
Company
Phone
Address
Supervisor
May we contact your previous supervisor for a reference?
Yes
No
Job Title
Responsibilities
Start & End Dates
Reason for Leaving
Work History #3
Company
Phone
Address
Supervisor
May we contact your previous supervisor for a reference?
Yes
No
Job Title
Responsibilities
Start & End Dates
Reason for Leaving
Education
HIGH SCHOOL:
Address
Did you Graduate?
Yes
No
Start & End Dates
Diploma
POST-SECONDARY:
Address
Did you Graduate?
Yes
No
Start & End Dates
Degree
OTHER:
Address
Did you Graduate?
Yes
No
Start & End Dates
Degree
Volunteer Experience
Company #1:
Phone
Address
Supervisor
Responsibilities
Start & End Dates
May we contact your previous supervisor for a reference?
Yes
No
Company #2:
Phone
Address
Supervisor
Responsibilities
Start & End Dates
May we contact your previous supervisor for a reference?
Yes
No
Other Experience Related to Respite Work
References
We require 3 work related references:
1. Full Name
Relationship
Company
Phone
Address
2. Full Name
Relationship
Company
Phone
Address
3. Full Name
Relationship
Company
Phone
Address
Disclaimer
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
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