Apply – Renaissance

Application

Last Name*

First Name*

Middle Initial

Last 4 digit of SSN

Address

Address 2

Apt/Floor

City*

State*

Zip*

Home Phone*

Mobile*

Email*

Emergency Contact Name*

Emergency Contact Phone*

Are you authorized to work in the US?*

Yes

Are you HHA Certified?*

Yes

Are you PCA Certified?*

Yes

If you are not certified, are you interested in the training course?*

Yes

Availability Agreement

1. I am available to work in the following areas:*

2. I am able to speak the following languages:*

English

Chinese

French

Russian

Creole

Cantonese

Spanish

3. I can start working:*

Immediately

or on the the following date

Date

4. Can you work Live-In cases?

Yes

5. Can you work with pediatric clients?

Yes

6. Can you work on the weekends:

Yes

7. Are you willing to work with COVID positive clients?

Yes

8. Are you willing to work with traumatic brain injury clients?

Yes

Consent Form

Text Messages

By signing this form, I authorize Renaissance Home Care of Renaissance to send text messages to my cell phone to alert me of available case opportunities, Timesheet links, HR matters, Compliance matters or any other company news related messages. I understand that standard text messaging, data and phone rates may apply to any messages received from RHHC and that RHHC is not responsible for payment of those fees. I understand that I may remove this permission in writing at any time. I further agree that in the event my cell phone number changes, I will inform HR department accordingly.

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I accept and DO want to receive text messages.

I decline and DO NOT want to receive text messages.

Cell Phone #:

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Cell Phone #:

Is this your primary phone?

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Yes

E-mail Messages

By signing this form, I authorize Renaissance Home Care of Renaissance to send e-mails to alert me of available scheduling opportunities, Timesheet links, HR matters, Compliance matters or any other company news related messages. I understand that I may remove this permission in writing at any time. I further agree that in the event my e-mail address changes, I will inform HR department accordingly.

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I accept and DO want to receive e-mails.

I decline and DO NOT want to receive e-mails.

E-mail Address :

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Is this your primary e-mail?

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Yes

I understand Renaissance Home Health Care may offer short hour assignments and will make every effort to offer additional short hour cases to provide caregivers with total hours of work at caregiver?s request. In order for HHA?s/PCA?s to remain in ACTIVE status, caregivers must work/provide service hours to patients continuously during employment. HHA?s/PCA?s that do not provide service hours for a period of 120 days may be terminated. I further understand that declining/refusing more than three cases in 30 day period may result in disciplinary action up to and including discharge. It is the responsibility of the HHA/PCA to communicate with the agency regarding changes to availability and to request cases to ensure compliance. I am aware that I cannot and will not work for other Licensed or Certified Home Care Agencies or any other organization during the hours that I am assigned to provide home health aide services to a patient of Renaissance Home Care of New York.

* I

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I have read, understand, and agree to abide by the complete agreement.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.
It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law. I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.
If hired, I agree to abide by all of the company rules and regulation, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. I understand that the Company and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of the Company, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the Executive Director or designee to make any agreement contrary to the foregoing.

I acknowledge that I have read and understand the above statements and1 hereby grant permission to confirm the information supplied on this application by me.”

How did you hear about us?

* Signature : Please sign with-in the signature pad highlighted in yellow below.

Signature*

Date

How did you hear about us?