Applicant – DiPromise

Have you ever been convicted of a criminal offence for which a pardon has not been granted?

Yes No

Are you currently working?

Yes No

Are you comfortable working in a COVID positive facility? *

Yes No

Languages Spoken

Other Languages (Please Specify)

Do you have CPR First Aid Certificate?

Yes No

Do you have General persuasion Approach (GPA) certificate?

Yes No

Did you work with individuals dealing with epilepsy?

Yes No

Do you have experience working with autistic children?

Yes No

Do you have a valid police background check (within the last 12 months)?

Yes No

Do you have a reliable vehicle?

Yes No

Do You Have a PSW Certificate?

Yes No

Do You Have Dementia Training and/or Experience?

Yes No

If Yes, please specify

Do You Have a CPR / First Aid Certificate ?

Yes No

Do You Have a Drivers Licence?

Yes No

Do You Have Acces to a Car?

Yes No

Do You Have Acces to Public Transit?

Yes No

What Areas are You Available to Work?

What Days are You Available for Work?

What Time(s) of Day are you Available for Work?

Morning Afternoon Evening Overnight

Add any Additional Time(s) of Day Availability Comments:

Attach Police Background Check

Attach Vaccination Proof

The facts set forth in my application for employment are true and complete. I understand that if employed, false statements on the application shall be considered sufficient cause for legal action as well as immediate dismissal without notice and without payment in lieu of notice. I consent to the information collected here being used to determine my eligibility and appropriateness for employment with Dipromise Health Care. I also consent to this information being used for identification and payroll purposes should Dipromise Health Care later employ me. I understand that I am responsible for my own transportation.

By submitting my Application online, I attest that I have read and understand the information contained above.