Residential Care for Trauma-Affected Youth at Jessie's Hope

1. Applicant Information

Full Legal Name *

Preferred Name

Street Address *

City *

State / ZIP *

Phone Number *

Email Address *

Date Available to Start

Desired Pay / Salary

Are you at least 18 years old? *

Yes No

2. Position & Availability

Position(s) Applying For *

Direct Care Staff Care Coordinator Residential Counselor House Manager Overnight Staff PRN / Relief Staff Volunteer Mentorship

Other Position

Employment Desired

Full-Time Part-Time PRN Temporary

Shifts Available

Days/Times Unavailable or Other Scheduling Restrictions

3. Group Home Experience & Qualifications

Describe any group home, residential, behavioral health, foster care, youth services, disability services or other direct-care experience.

Why do you want to work in a group home, and what strengths would you bring to the residents?

Are you willing to work respectfully with residents from diverse backgrounds and maintain professional boundaries? *

Yes No

Are you willing to assist with daily living activities as assigned, including meals, housekeeping, transportation, appointments, routines and supervision? *

Yes No

Are you willing to follow individualized service/support plans, house rules, safety procedures and supervisor instructions? *

Yes No

Are you comfortable completing accurate and timely shift notes, incident reports and other required resident documentation? *

Yes No

Can you perform the essential functions of the position, with or without reasonable accommodation? *

Yes No

4. Education, Training & Certifications

Highest Education Completed

School / Program

Relevant Degree / Coursework

Current Certifications

CPR First Aid Medication Administration Crisis Prevention / De-escalation

Other Certifications

5. Employment History

Employer 1

Employer / Organization

Job Title

Supervisor / Phone

Dates Employed

Reason for Leaving

Key Duties

May we contact this employer?

Yes No

Employer 2

Employer / Organization

Job Title

Supervisor / Phone

Dates Employed

Reason for Leaving

Key Duties

May we contact this employer?

Yes No

Employer 3

Employer / Organization

Job Title

Supervisor / Phone

Dates Employed

Reason for Leaving

Key Duties

May we contact this employer?

Yes No

6. Driving & Transportation

Do you have a current, valid driver's license? *

Yes No

Driver's License State

Expiration Date

Do you have reliable transportation to report to scheduled shifts? *

Yes No

Driving restrictions that may affect job duties

7. Professional References

Reference 1

Name

Relationship / Organization

Phone / Email

Years Known

Reference 2

Name

Relationship / Organization

Phone / Email

Years Known

Reference 3

Name

Relationship / Organization

Phone / Email

Years Known

8. Résumé Upload

Upload Your Résumé

Accepted file types: PDF, DOC, DOCX. Please upload your most current résumé.

9. Training & Screening

Are you willing to complete required orientation and training, which may include CPR/First Aid, medication administration when applicable, crisis prevention/de-escalation, abuse/neglect reporting, confidentiality and resident rights? *

Yes No

Job-related background checks, driving-record reviews and other screenings may be completed separately when applicable and after any notices or authorizations required by law.

10. Applicant Certification

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that material misrepresentation or omission may disqualify me from consideration or may result in termination, subject to applicable law. I understand that this application is not a contract or guarantee of employment.

I have read and agree to the applicant certification above. *

Typed Signature (Full Name) *

Date *

Employment Application

1. Applicant Information

2. Position & Availability

3. Group Home Experience & Qualifications

4. Education, Training & Certifications

5. Employment History

Employer 1

Employer 2

Employer 3

6. Driving & Transportation

7. Professional References

Reference 1

Reference 2

Reference 3

8. Résumé Upload

9. Training & Screening

10. Applicant Certification