Thank you for choosing Visiting Angels!

It is important to us that you not only find it personally rewarding to provide care for others, but that you take pride and great joy in working with our agency. Therefore, we go to great lengths to make caregiving with us different from other agencies. Below is a snapshot of ways that we make caregiving with Visiting Angels unique from other agencies. Flexible Scheduling Schedule needs are determined by the client and we have all sorts of needs: small hours, medium hours, and big hours. The only limitation is you. 1. If you want to work as many hours as possible, including overtime, let your supervisor know! We understand and want to provide you with as much opportunity as possible! 2. If you do not want to work that much and only want small hours, let your supervisor know! We will be as flexible with you as possible and will not force anyone to work hours they do not want to work. Employee Choice Caregivers are able to choose their path. Caregivers who want health benefits may choose to become a Select SP Caregiver and work with state funded clients. Caregivers who desire more flexibility in their earning power may choose to become an Exclusive CP Caregiver and work with private pay clients. Whatever the reason, the choice is yours! Higher Pay Rates We are one of the higher paying, non-medical, agencies. 1. See the backside for our current pay rates. 2. Quarterly bonus opportunities allow caregivers to earn as much as $200 or more depending on the number of hours worked in that quarter. 3. Exclusive CP Caregivers generally earn a special pay rate, which is above and beyond their normal pay rate, when working assignments that are less than four hours. 4. We are non union; therefore, we do not deduct any amount from your paycheck except as required by law. Health Benefits Select SP Caregivers are eligible to enroll in our health benefits plan when they average 87 hours or more per month. For only $17.50 per month, you get the same plan that the office staff and owners have! AFLAC Visiting Angels has partnered with a local AFLAC representative to offer supplemental health benefits coverage. Some of these benefits are pre-tax. 5% Vehicle Insurance Discount Visiting Angels has partnered with a local Met Life insurance representative who can offer a 5% discount on car insurance. When the Owners met with the representative they found that the insurance was better and less expensive than their previous carriers before the discount was offered. 401K Visiting Angels will match your 401K contributions up to 4% of your annual earnings. Personal Touch We are structured differently from other agencies by having more managers and office personnel. This structure allows us to cultivate relationships and focus on people.

Thank you for choosing Visiting Angels!

July 2009 June 2010 Pay Rates

Select SP Caregivers (those who work with state funded clients) Those who have no certification start at $9.80 per hour for hourly assignments. Those who have the Fundamentals of Caregiving start at $10.05 per hour for hourly assignments.

Exclusive CP Caregivers (those who work with private pay clients) Those who have no certification start at $9.80 per hour for hourly assignments and $132.00 per shift for live-in assignments. Those who have the Fundamentals of Caregiving Certificate start at $10.05 per hour for hourly assignments and $137.00 per shift for live-in assignments. Those who maintain an active Nurse Assistant Certified license start at $10.30 per hour for hourly and $142.00 per shift for live-in assignments. Those who have a Nurse Delegation Certificate and maintain licensure requirements for nurse delegation duties can earn an additional $1.00 or more per hour on nurse delegation assignments. When scheduled for less than three hours Exclusive CP Caregivers can earn an additional $3.00 per hour. Ask a supervisor for details. Upon successful completion of your first 90 days without a Basic 12 violation you are eligible for up to a $.25 per hour increase for hourly assignments and up to $5.00 per shift for live-in assignments. Ask a supervisor for details.
This handout is provided as a reference to our current pay rate structure and is subject to change at any time.

Date:

Where did you see our help wanted ad? Newspaper Web Phone Book Friend Other: _______________________________
MI City City Cell Phone: Email Address: Last Name

Employment Application

First Name Address Mailing Address Phone:

State/Zip State/Zip Social Security Number:

Have you worked for Visiting Angels before?

No

Yes. Provide dates if yes: No Yes. Provide details if yes.

Do you have a Non-Compete or other agreement that might restrict employment?

Availability
Visiting Angels is 24/7, meaning that we serve clients 24 hours a day, 7 days a week. Please indicate below what hours you are willing and able to work and which counties you are willing to work in or if you are limited to the bus system. Available In:
(Circle all that apply)

WHATCOM County Split Shifts Days

SKAGIT County Short Shifts (1-3 hours) Evenings

ISLAND County Normal Shifts (4-10 hours) Overnight

SAN JUAN Islands 12 Hour Days Weekdays

SNOHOMISH County 12 Hour Nights Weekends

BUS LINE Only Live-In Shifts On Call/Short Notice Shifts

Able to Work:
(circle all that apply)

Able to Work:
(circle all that apply)

NOT AVAILABLE:

Certification & Training

Visiting Angels hires people with a wide variety of training and certification. Please indicate below, with the date, which training classes you have completed. Fundamentals of Caregiving NAR License NAC License Nurse Delegation Other: State: State: State: State: State: Date Completed: Date Completed: Date Completed: Date Completed: Date Completed: To be completed on: To be completed on: To be completed on: To be completed on: To be completed on:

Limitations
Please identify any limitations you may have that may prevent you from performing any function of a caregiver, such as lifting, bending, standing, staying alert, working in a smoking or non-smoking environment, working with pets, allergies, etc. No, I do not have limitations Yes, I do have limitations. Explain below.

Personnel

Application

Application

Job History (starting with the most current)

Visiting Angels will contact your previous employers unless otherwise indicated. Company Name: City/State: Job Description: May we contact? If not please indicate reason. Company Name: City/State: Job Description: May we contact? If not please indicate reason. Company Name: City/State: Job Description: May we contact? If not please indicate reason. Supervisor: Phone Number: Reason you left: Rate of Pay: Dates Employed: Supervisor: Phone Number: Reason you left: Rate of Pay: Dates Employed: Supervisor: Phone Number: Reason you left: Rate of Pay: Dates Employed:

Personal References (other than relatives)

Name: Name: Name: Name: Name: Relationship: Relationship: Relationship: Relationship: Relationship: Phone Number: Phone Number: Phone Number: Phone Number: Phone Number: Years Known: Years Known: Years Known: Years Known: Years Known:

Education
High School Diploma or Equivalent: College: Years completed: Years completed:

I certify that the information given by me is true and complete to the best of my knowledge. I understand that if I am employed, the discovery that I gave false information during the application process may result in immediate dismissal. I authorize Visiting Angels, to which I am providing this application to investigate all statements contained in this application and to request information about me from previous employers, educational institutions, and references. I expressly authorize my previous employers to provide information and opinions concerning my work and work habits. Further, I release all parties (including Visiting Angels) and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason, arising out of furnishing any information. If employed, I release Visiting Angels from any liability for future references it may provide regarding my work history with them. I understand Visiting Angels cannot guarantee that my application will be considered for any or all open positions they may have or that my application will be considered for any specific time. In the event of employment, I understand that I am required to abide by all current and subsequently issued rules and regulations of Visiting Angels and that my employment and compensation may be terminated, at any time, with or without notice, by either party. x Print Name
Personnel Application

x Sign Name
Application

x Date

Self Assessment of Skills

Page 1 of 2 When asked to assess your experience only include real world experience. Clinical experience, while valuable, is not to be included in your assessment.

Companion Care
How much experience do you have with Companion Care (check one):
None < 3 months 3 6 months 6 12 months 1 3 years 3+ years

Check three areas of Companion Care you have a special talent with or are comfortable providing: Reading to them Accompanying them to church/activities Taking them on errands Watching television with them Playing games with them Talking about current events Going on walks or drives Helping them with their hobbies/interests Preparing meals Housekeeping & laundry Other: ___________________________ Other: ___________________________

Personal Care
How much experience do you have with Personal Care (check one):
None < 3 months 3 6 months 6 12 months 1 3 years 3+ years

Indicate your level of comfort performing the following tasks with another person:
Not comfortable Dressing Personal Hygiene Bathing Toileting Incontinence Somewhat comfortable Very comfortable

Skills and Equipment

Identify your level of comfort with each skill and item:
Not comfortable Transfer (Assist & Pivot) Using a Gait Belt Using a Hoyer Lift Cleaning a Catheter Clean a Commode Somewhat comfortable Very comfortable Approximately, how often have you performed?

Personnel

Application

Self Assessment of Skills

Self Assessment of Skills

Page 1 of 2

Specific Disabilities & Conditions

Indicate your interest and level of experience with the following disabilities and conditions. Alzheimer/Dementia
Interest: Experience: No Interest None Some Interest < 3 months 3 6 months High Interest 6 12 months 1 3 years 3+ years

Severe Disabilities
Interest: Experience: No Interest None Some Interest < 3 months 3 6 months High Interest 6 12 months 1 3 years 3+ years

Autism
Interest: Experience: No Interest None Some Interest < 3 months 3 6 months High Interest 6 12 months 1 3 years 3+ years

Developmentally Delayed
Interest: Experience: No Interest None Some Interest < 3 months 3 6 months High Interest 6 12 months 1 3 years 3+ years

Hospice
Interest: Experience: No Interest None Some Interest < 3 months 3 6 months High Interest 6 12 months 1 3 years 3+ years

x Print Name

x Sign Name

x Date

Personnel

Application

Self Assessment of Skills

Personnel

Background

Background Application

Personnel

Background

Background Application

Personnel

Background

Background Application

FAX
TO: FROM:

This is a confidential message, intended solely for the person to whom it is addressed. If you receive this message in error, please forward it to the correct person, or mail it back to us. Thank you.
VISITING ANGELS FAX: VISITING ANGELS PHONE:

THIS SECTION TO BE COMPLETED BY APPLICANT

I authorize Visiting Angels, to which I am providing this application to investigate all statements contained in this application and to request information about me from previous employers, educational institutions, and references. I expressly authorize my previous employers to provide information and opinions concerning my work and work habits. Further, I release all parties (including Visiting Angels) and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason, arising out of furnishing any information. If employed, I release Visiting Angels from any liability for future references it may provide regarding my work history with them.

Please print name clearly

Signature (required)
THIS SECTION TO BE COMPLETED BY REFERENCE

Date

Visiting Angels is a non medical, in home care agency that provides caregivers for vulnerable seniors and developmentally disabled children for one-on-one care. Some common responsibilities of our caregivers include assisting with medication, light house keeping, and personal care. Because of the vulnerability of the people we care for we value any insights you can offer about the applicant.
Reference Name: Phone: Place of Employment: Dates Employed/Years Known:

Are the above dates of employment correct? Position held: Eligible for rehire? Yes No Please explain:

1. Visiting Angels values include Integrity, Teamwork, and Service. How have you seen this applicant demonstrate those qualities?

2. What special abilities would this applicant bring to the role of caregiver?

3. What personal characteristics does this applicant have that would be helpful in this job?

4. Do you believe the applicant is qualified to care for seniors or children? What have you observed that led you to that conclusion?

5. Is there anything that would concern you about placing this applicant in the home to care for a senior or child?

1. Dependability/Attendance. 2. Attitude......

Good ( ) ( )

Average ( ) ( )

Poor ( ) ( )

3. 4.

Integrity. Good with Seniors.

Good ( ) ( )

Average ( ) ( )

Poor ( ) ( )

Signature:

Title:

Personnel

Application

Reference Fax Form