Name: Schofield Care
Address: NY

To Applicant: We deeply appreciate your interest in our training program and assure you that we are sincerely interested in your qualifications. A clear understanding of your background will assist us in considering your application for training. Please answer ALL questions.

Personal

Full Name

Are you at least 18 years of age?

Yes

No

Email Address

Primary Telephone Number

Secondary Telephone Number

If no, what is your date of birth?

Training Applied For

PCA

HHA

What prompted you to apply here for training?

Have you previously been employed by us?

Yes

No

If yes, when?

Position?

Do you have any relatives working for us?

Yes

No

If yes, Name:

Do you have any friends working for us?

Yes

No

If yes, Names:

Are there any other experiences, skills or qualifications which you feel would especially fit you for PCA/HHA work?

Personal References (Do not include relatives or former Employers)

Reference 1

Name

Occupation

Phone Number

Reference 2

Name

Occupation

Phone Number

Reference 3

Name

Occupation

Phone Number

State and federal laws prohibit discrimination on the basis of race, color, marital status, creed, sex, national origin, sponsor, disability, handicap, age, veteran status, or sexual preference.

Employment Record

List present and most recent positions (beginning with most recent).

Employer 1

Name of Employer

From

To

Reason for leaving

Name of Supervisor

Describe in detail the work you did

Job Title

Employer 2

Name of Employer

From

To

Reason for leaving

Name of Supervisor

Describe in detail the work you did

Job Title

Employer 3

Name of Employer

From

To

Reason for leaving

Name of Supervisor

Describe in detail the work you did

Job Title

Employer 4

Name of Employer

From

To

Reason for leaving

Name of Supervisor

Describe in detail the work you did

Job Title

Have you ever been convicted of a felony, misdemeanor, or other offense?

Yes

No

If yes, this does not automatically disqualify you for training. Please provide details:

Education

Name of High School

Course of Study

Number of years Attended

1

2

3

4

Did you Graduate?

Yes

No

List Diploma or Degree

Name of College or Specialty School

Course of Study

Number of years Attended

1

2

3

4

Did you Graduate?

Yes

No

List Diploma or Degree

PCA/HHA Training Questionnaire

Please answer each question.

How did you hear about Schofield?

Buffalo News

Other Newspaper

Telephone Book

Schofield Home Health Care Employee

Schofield Residence Employee

Word of Mouth

Other

Aside from helping others, why do you want to be a personal care aide (PCA)/home health care aide (HHA)?

What duties would you expect to have as a PCA/HHA? Please list all you are aware of:

List some negative aspects of the job that you would expect to encounter as a PCA/HHA

What traits/characteristics do you think a successful PCA/HHA must have?

How do you feel about old people that some may describe as "crabby and confused"?

I understand that being accepted into the training program does not in any way constitute an offer of employment with Schofield Home Health Care Services, Inc. Successful completion of the training program may lead to a NYS approved certificate, and eligibility to apply for employment with any home care agency in New York State.

Applicant Signature

Reset

PCA/HHA Training Enrollment Application

PCA/HHA Training Enrollment Application

Personal

Personal References (Do not include relatives or former Employers)

Employment Record

Education

PCA/HHA Training Questionnaire