VALLEYLIFE
1142 West Hatcher Road  ◙  Phoenix, Arizona 85021  ◙  (602) 371-0806
APPLICATION FOR EMPLOYMENT
We consider applicants for all positions without regard to race, color, religion, creed, national origin, age, marital or veteran status, sexual orientation, or any other legally-protected status. WE ARE AN EQUAL OPPORTUNITY EMPLOYER.
VALLEYLIFE
PERFORMS POST-OFFER WORKER'S COMPENSATION BACKGROUND CHECKS
   
PART I - PERSONAL INFORMATION
Applicant's Name:
Address:
City:
State:                                                                     Zip code:   
Phone:
Phone:
Email address:
 
PART II - POSITION INFORMATION
Position applied for:
Have you ever filled out an application with us before?
If yes, give date:
In order to track our referrals, we ask that you tell us where you heard about this position:
If referred by a current employee, please supply their name:
Have you ever been employed with us before?
If yes, give date:
Are you currently employed?
May we contact your current employer?
Are you prevented from becoming lawfully employed in this country?
Are you currently on "layoff" status and subject to recall?
On what date are you available to start work?
Have you been convicted of any felony in the last 10 years?
 
Are you available to work:  
      PART TIME       SUB STATUS
 
AVAILABLE SHIFTS: (check all for which you would like to be considered)

DAY SERVICES:                                                                                                         HOME AND COMMUNITY BASED SERVICES:
7 AM - 4 PM MONDAY-FRIDAY                                               VARIOUS HOURS

RESIDENTIAL
 3:00 PM  - 11:00 PM  VARIOUS DAYS, MAY INCLUDE WEEKENDS
11:00 PM -  7:00 AM  VARIOUS DAYS, MAY INCLUDE WEEKENDS
7:00 AM - 7:00 PM SATURDAY AND SUNDAY
7:00 PM - 7:00 AM SATURDAY AND SUNDAY
SUBSTITUTE, ON-CALL SHIFTS
 
DRIVING REQUIREMENT:

Employee eligibility to drive company vehicles is required for many positions. Please assist us further in evaluating your qualifications by completing this section. Check only one box.

Please note that all drivers must provide a valid Arizona driver's license.

 
PART III - EDUCATION
High School:
Location:
Course of study:
Years completed:
Degree or diploma earned:
   
Undergraduate School:
Location:
Course of study:
Years completed:
Degree or diploma earned:
   
Graduate School:
Location:
Course of study:
Years completed:
Degree or diploma earned:
   
Other:
Location:
Course of study:
Years completed:
Degree or diploma earned:
 
PART iv - SKILLS (please check all that apply)
CPR
ISP
First aid
Sign Language
Behavior Management
Basic Supervision
CIT
Article IX
Computer Skills
Foreign Language          Fluent?   Please explain:
 
PART V - EMPLOYMENT HISTORY (most recent first)
Employer:
Address:
Phone:
 
From:
To:
  
   
Starting salary:
Ending salary:
Supervisor:
Reason for leaving:
Duties performed:
   
Employer:
Address:
Phone:
 
From:
To:
  
   
Starting salary:
Ending salary:
Supervisor:
Reason for leaving:
Duties performed:
   
Employer:
Address:
Phone:
 
From:
To:
  
   
Starting salary:
Ending salary:
Supervisor:
Reason for leaving:
Duties performed:
 
PART VI - REFERENCES (these areas must be complete)
WORK
Name:
Address:
Phone:
   
Name:
Address:
Phone:
   
Name:
Address:
Phone:
PERSONAL (not related to you)
Name:
Address:
Phone:
   
Name:
Address:
Phone:
   
Name:
Address:
Phone:
EMRGENCY CONTACT
In case of an emergency, whom should we contact?
Name:
Relationship:
Address:
Phone:
Name:
Relationship:
Address:
Phone:
PART VIi - APPLICANT QUESTIONNAIRE (please answer in complete sentences Any questions left                                                                             blank may delay your application process)
1. How do you view children and adults with developmental disabilities?
2.  Do you have any knowledge of developmentally disabled individuals and their special needs? If yes, please
     describe briefly your experience:

3. You may be required to work with individuals with behavioral needs.
     Are you willing and able to perform this duty?


4.   Do you have any experience in working with behavioral issues?? If yes, please
     describe briefly:
5. You may be required to bathe, clothe and feed a developmentally disabled individual. Are you willing and able to
    perform these tasks?    
6. You may be required to assist in the hygiene of a disabled individual.Are you willing and able to perform
     these tasks?    
7.   Employees are required to do extensive heavy lifting (40 lbs. or more) during an
      8- or 12- hour shift.  Are you willing and able to perform this task?    

8. You may be required to bend your knees to a squat position (keeping your back straight) to lift
    someone up from the floor or to put them into a bathtub for bathing? Are you willing and able to do this task?


9. You may be required to change soiled items on developmentally disabled individuals 
    (male or female). Are you willing and able to do this task?    


 
PART VIII - EEO SELF-IDENTIFICATION

VALLEYLIFE is an equal employment opportunity employer. Certain laws and regulations regarding equal employment opportunity require us to compile annual statistical reports on applicants for employment and employees. In order to comply with these laws and regulations, we are requesting your cooperation in completing this EEO Self Identification Form.

The information on this EEO Self-Identification Form is being requested and will be used solely for equal employment opportunity record-keeping and reporting purposes. Submission of this form by you is voluntary. Please be assured that you will not be subjected to any adverse treatment if you do not provide the information requested. In the event that you do provide the information requested, the information and this form will be processed and maintained separately from your employment application forms and, if hired by the Company, your personnel file.
Sex Identification:  
Minority Identification:  
 
PART IX - APPLICANT'S STATEMENT
I certify that answers given herein are true and complete to the best of my knowledge.

I authorize the investigation of all statements contained in this application for employment
as may be necessary in arriving at any employment decision

This application will be considered active for a period of time not to exceed forty-five (45) days.
Any applicant wishing to be considered for employment beyond this time should inquire as to
whether or not applicants are being accepted at this time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any
employment relationship with this organization is of an "at will" nature, which means that the
employee may resign at any time and the employer may discharge employee at any time
with or without cause. It is further understood that this "at will" employment relationship
may not be changed by any written document or by conduct unless such change is
specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my
application or interview(s) may result in discharge. I understand also that I am required to
abide by all rules and regulations of the employer.

I agree to the above statement.

 
Today's date: