Required fields are marked with asterisks (*)

Application for Personal Support Worker

Applicant Information

Last Name

First Name

Street Address

City, Province

Postal Code

Home Phone Number

Cell Phone Number

Email Address

What position are you applying for?

Please indicate the Home you would like to consider this application for employment:

Bonnechere Manor (Renfrew)

Miramichi Lodge (Pembroke)

What type of work are you interested in? Please check all that apply.

Full-Time

Part-Time

Relief

Student * must provide proof of full time student status

Are you permitted to work in Canada?

Yes

Are you over the age of 16?

Yes

When are you available to start?

Immediately

Two weeks

Other

If other, please explain

Please indicate which shifts you are available for? Please check all that apply.

Days

Evenings

Nights

All

Have you ever worked for the County of Renfrew?

Yes

If yes, please provide position held and year(s)

Have you ever worked for Bonnechere Manor or Miramichi Lodge?

Yes

If yes, please provide position held and year(s)

Have you ever been convicted of a criminal offence for which a pardon has not been granted? Note that Police Record Check, with Vulnerable Sector Screening, completed within the last six months is a condition of employment.

No, I do not have a police record

Yes, I do have a police record and will discuss if selected for an interview

Educational Information - List most recent first

Name of School

City/Location of school

Name of program

Graduated

Yes

Diploma/Degree/Certificate

Name of School

City/Location of school

Name of program

Graduated

Yes

Diploma/Degree/Certificate

Name of School

City/Location of school

Name of program

Graduated

Yes

Diploma/Degree/Certificate

Additional Courses, Training or Relevant Certificates (list below):

Employment Experience - List most recent first

Name of Company

Position Title

Start Date

End Date

Reason for Leaving

Name of Company

Position Title

Start Date

End Date

Reason for Leaving

Name of Company

Position Title

Start Date

End Date

Reason for Leaving

Why do you want to work in long-term care and specifically in our Home?

Please explain:

Job Requirements

All employees are expected to review and sign a confidentiality policy related to the safeguarding of information related to residents, employees, volunteers and Home business.

The following are Job Requirements. Please indicate if you currently have these requirements or are willing to obtain priorto orientation if you are the successful candidate:

* Information on where to obtain certificates required will be provided with offer of employment or upon request.

Personal Support Worker Certificate

I have

I will receive

Select date to receive certificate

Proof of Vaccination or Immunity to the following:

Hepatitis B, Varicella, Measles, Mumps, Rubella

I have

I will obtain

Influenza Vaccine – Annual Expectation

I have

I will obtain

Tuberculosis Test – Step One (within last year)

I have

I will obtain

Tuberculosis Test – Step Two

I have

I will obtain

Tetanus shot – Current in last 10 years

I have

I will obtain

Safe Food Handlers Certificate

I have

I will obtain

Accessibility for Ontarians Act Certificate

I have

I will obtain

Ministry of Labour’s Worker Health and Safety Certificate

I have

I will obtain

Gentle Persuasive Approach Certificate

I have

I will obtain

Job Assests

The following are considered assets. Please indicate if you currently have these assets:

CPR current?

Yes

If yes, please provide date

Do you have experience with the following computer technology:

Point Click Care

Staff Schedule Care

Other related job assets:

Please attach your resume (3 MB max.)

Browse…

Allowed extensions pdf, doc, docx

Terms and Confirmation of Application

The County of Renfrew will make efforts to provide this document in an accessible format or with communication support, on request. We will consult with the person making the request to determine the suitability of the format or communication support. We will provide the accessible format in atimely manner and, at no additional cost.

The County of Renfrew is an equal opportunity employer. Accommodation will beprovided in accordance with the Ontario Human Rights Code.

The County of Renfrew will only use the information you provide in response to a jobadvertisement for recruitment purposes and your application will be kept on file for six(6)months.

Only those individuals selected for an interview will be contacted.

Information collected will be handled in accordance with the Municipal Freedom of Information and Protection of Privacy Act

Please confirm:

I confirm that I am applying for employment with Bonnechere Manor and/or Miramichi Lodge Long Term Care Home(s)

I have attached a current resume to this application

I have read, completed and understand the questions on this form; the information I have provided is truthful to the best of my knowledge. I have full knowledge and understanding that if it is found that I have falsified this application, and I am hired,

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Application for Personal Support Worker

Applicant Information

Educational Information - List most recent first

Employment Experience - List most recent first

Why do you want to work in long-term care and specifically in our Home?

Job Requirements

Job Assests

Terms and Confirmation of Application