Another Day Care Giver Information Form

Another Day, Inc. is looking for qualified, compassionate care providers to help aid individuals with disabilities. The care provider will assist the individual in performing a variety of tasks promoting independence, productivity, and integration. These services are provided for individual both in their homes and in the community. Typical tasks include helping with mobility, exercise activities, meal preparation, feeding, transferring, grooming, and health maintenance activities -

This is an informational form ONLY and NOT an employment application. Another Day, Inc. will review your information and may contact you to request that you complete a formal employment application.

Thank you

Website: www.anotherday.info
Address: 11802 West 77th Street, Lenexa, Kansas 66214
Fax: 913-599-5660

Use the form below to send an email to us. The fields marked with * are required.
Name (First & Last)*:
Today's Date:
Address:
City / State / Zip:
Phone*:
Cell:
Alt:
Email*:
What are the maximum hours per week that you are available to work?
What is the maximum distance you are willing to travel?
What college did you attend?
How did you hear about us?
What language(s) to you speak?
if other:

Missouri Kansas
County: County:
If other If other

Days and hours that you would be available:
MON TUE WED THU FRI SAT SUN
Day
Evening
Night
Please enter the time(s) in the appropriate boxes above. If you are not available to work on a day, do not fill in the box for that day. An example would be if you can work on Mondays during the day, go to the "MON" column, the "Day" row and enter the hours "1pm - 3pm"

Job Experience:
Certifications:

Please be aware that you are only submitting information in order for Another Day to contact you. This information does not imply or guarantee work. You must have contact with the office and undergo a background check before employment can be offered. By checking this box you agree to having had read this disclosure.
I affirm that all of the information provided above is accurate to the best of my knowledge and I understand that falsification of any of this information is cause for immediate termination and possible litigation.
I have also read and agree to the terms of disclosure of this information*.
 Yes No
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