Direct Support Worker Application

Most Recent Employer: *

•

Are you comfortable with more personal tasks such as bathing, toileting, and wheelchair assistance? *

Yes

College Degree/Course of Study:

Dates employed at Employer #3:

HOME

Job Title at Employer #2:

Job Duties at Employer #3:

Previous Employer #3: *

Previous Employer #2: *

Last Name: *

Apply for Services

Job Duties at Most Recent Employer: *

Dates Employed at Employer #2:

Reason for leaving Employer #2:

Have you ever been convicted of a crime? (Must pass the following background checks: KBI, Child & Adult Abuse, KDHE, OYG) *

Yes (see next question)

Employer #3 Address and Phone Number:

ABOUT US

Most Recent Employer Address and Phone Number: *

If Yes, please list employment dates and reason for leaving:

Professional Reference #3: (Please provide: Name, Address, Phone number, Relationship, and Years acquainted) *

Notes or Additional Information:

Are you 18 or over? *

Yes

Are you able to lift 60 - 80 pounds? *

Yes

AFTER APPROVED - How to clock in/out

Job Title at Employer #3:

Employer #2 Address and Phone Number:

Reason for leaving (if applicable): *

Time changes/corrections

Employed From: *

Supervisor at Most Recent Employer: *

High School: *

RECEIVE SERVICES

•

Are you currently employed? *

Yes

If yes, please explain:

Supervisor at Employer #2:

DEVELOPEMENT of LIFE PATTERNS, INC.

Driver's License #: *

Job Duties at Employer #2:

•

Application & Forms - if hired by family already

Professional Reference #1: (Please provide: Name, Address, Phone number, Relationship, and Years acquainted) *

Have you ever worked for a Family/Individual that uses Life Patterns as their FMS provider? *

Yes (see next question)

College:

First Name: *

Do you have a valid driver's license? *

Yes

SUPPORT WORKERS

This Support Worker Application is for people that do NOT already have an Individual/family lined up to work for.

If you have a Individual/family that you have already spoke with about working for you, you will need to PRINT THESE FORMS (click highlighted text to be directed to correct forms) and return to us via mail or in person to our office in Topeka, KS.

*Filling out this application allows us to share with our Individuals/families who work through us as their FMS provider that may be looking for workers.

*We are NOT a staffing agency. The Individual/family is (are) your employers.

Reason for leaving Employer #3:

Graduated High School? *

Yes

APPLICANT'S STATEMENT: I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application. I authorize anyone possessing this information to furnish it to Life Patterns, Inc. upon request. I release anyone so authorized and Life Patterns, Inc. from all liability and damages whatsoever in furnishing, obtaining, or using said information. In the event of employment, I understand false or misleading information given on my application or interview(s) may result in immediate dismissal. I understand also I am required to abide by all rules and regulations of Life Patterns, Inc. I understand the receipt of this application by Life Patterns, Inc. does not imply employment and this application and/or any other Life Patterns, Inc. documents are not contracts of employment. I understand that, in the event of employment, just as I am free to resign at any time, Life Patterns, Inc. reserves the right to terminate my employment at any time, with or without cause and without prior notice. *

Agree

Disagree

What is the highest level of education that you have completed? *

Job Title at Most Recent Employer: *

Supervisor at Employer #3:

Driver's License State of Issue: *

Phone

PAY STUBS

When are you available to start? *

Professional Reference #3: (Please provide: Name, Address, Phone number, Relationship, and Years acquainted) *