Apply for AFC CAREGIVER

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

Summary
Title:AFC CAREGIVER
ID:1006
Location:N/A
Department:Direct Care Aides
Resume
Resume:
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* Social Security Number:
* Date of Birth:
Opt-In Confirmation
I authorize recruiters from Epic Nursing Services to send text messages from 8664856934 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.
AFC Caregiver Questionnaire
* Emergency Contact Name:
* Emergency contact Phone Number:
* Role
Caregiver
Backup Caregiver
* How did you hear about our program?
* What is the name of the AFC member you are applying for?
* What is the relationship with the AFC member?
* Do you have any physical limitations or diagnoses that might prevent you from rendering hands on care?
Yes
No
* If yes, please specify
* Do you have any special training e.g., Alzheimer's or Behavioral health training?
Yes
No
* Do you have a diagnosed drug or alcohol abuse disorder?
Yes
No
* Have you previously worked in homecare or as a caregiver?
Yes
No
* Do you provide services to any other AFC client?
Yes
No
* Please list all family members and non-relatives living in your home, including yourself. Please include age and relationship to caregiver.

Reference 1

* Full Name
* Phone Number
* Relationship

Reference 2

* Full Name
* Phone Number
* Relationship

Reference 3

* Full Name
* Phone Number
* Relationship
* Pay schedule
caregiver for Level 1 client: $26.50 per day
Caregiver for Level 2 Client: $54.56 per day
* I have read the above rates and agree that these rates are satisfactory and acceptable to me.
Yes
No
* I have read the above rates and do not accept these rates, therefore do not desire employment with Epic Nursing Services at this time.
Yes
No
* Signature
* Date
Acknowledgement Consent Form

OIG Consent Form

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that that Epic Nursing Services LLC, or its authorized agent will conduct an initial and monthly check of the OIG’s List of Excluded Individuals/Entities (LEIE). I hereby acknowledge and provide permission to Epic Nursing Services, LLC or its authorized agent to submit such periodic checks for my information. This authorization is valid for the entire tenure of my employment with this organization. I consent to an OIG background check and affirm that the information provided on this Acknowledgement Form is true and accurate.
Yes
No

CORI Consent Form

* Epic Nursing Services LLC is registered under the provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing.
As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I
hereby acknowledge and provide permission to Epic Nursing Services LLC to submit a CORI check for my information to the DCJIS. This authorization is valid throughout my employment tenure with the Agency.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
By consenting below, I provide my consent to a CORI check and affirm that the information provided is true and accurate.
Yes
No

Sex Offender Registry Investigation Consent

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that a Sex Offender Registry Investigation (SORB) will be submitted for my personal information. I hereby acknowledge and provide permission to Epic Nursing Services, LLC or its authorized agent to submit a SORB check for my information. This authorization is valid throughout my employment tenure with the Agency.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
By consenting below, I provide my consent to a SORB check and affirm that the information provided is true and accurate.
Yes
No

Nurse Aide Registry Check

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that abuse checks will be conducted via the Nurse Aide Registry where my personal information will be submitted. I hereby acknowledge and provide permission to Epic Nursing Services, LLC or its authorized agent to submit a NAR check for my information. This authorization is valid throughout my employment tenure with the Agency.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
Epic Nursing Services, LLC may conduct subsequent NAR checks throughout my employment tenure with the agency.
By signing below, I provide my consent to a NAR check and affirm that the information provided on this Acknowledgement Form is true and accurate.
Yes
No
* Signature

Driving Record Check Consent

* Date
* I hereby authorize Epic Nursing Services LLC and its designated agents and representatives to conduct a comprehensive review of my driving record through a consumer report and/or an investigative consumer report to be generated for insurance purposes.
Yes
No

Emergency Contact

* Emergency Contact Name
* Emergency contact Phone Number
* Emergency Contact Address
* Emergency Contact Relationship
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
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
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
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

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.
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