Post Falls Employment Application – Community Connections, Inc.

EOE / Employment Eligibility Statement

Community Connections, Inc. is an Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, creed, color, religion, gender, national origin, age, citizenship, disability, special needs status, marital status, or any other basis protected by applicable Federal, State, or Local law. Identity and employment eligibility of all new hires will be verified as required by the Immigration Reform and Control Act of 1986.

Incomplete applications will not be considered. A resume will not be accepted in lieu of a properly completed application.

Per State law, employees working in our Supported Living program must be 18 years of age or older. Anyone hired for a Supported Living position who does not meet the State’s age requirement, per law, cannot work within the program and may forfeit employment.

This form is encrypted and the information you submit is password protected. Community Connections, Inc will not share your information with any third-parties without your consent.

Applicant Information

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Cell Phone Number(Required)

Email(Required)

Social Security Number(Required)

Emergency Contact(Required)

Phone Number(Required)

Are you authorized to work in the U.S.?(Required)

Yes

Do you have a reliable vehicle (excluding motorcycles / mopeds)?(Required)

Yes

Are you CPR and First Aid Certified?(Required)

Yes

Do you have a valid Driver's License?(Required)

Yes

Are you Medication Certified (SAM)?(Required)

Yes

Do you have automobile insurance?(Required)

Yes

Have you ever worked for this company?(Required)

Yes

Have you had a background check with the Idaho Department of Health & Welfare in the past 3 years?(Required)

Yes

Are you free of communicable diseases and skin lesions?(Required)

Yes

Education

High School(Required)

Still Attending?(Required)

Yes

Did you graduate?(Required)

Yes

GED

Highest Grade Completed:(Required)

Can you provide proof of graduation/GED (i.e. copy of diploma/degree)(Required)

Yes

College/University

Graduation Date (Month/YR)

Did not graduate

Did not Graduate

Degree Type

Bachelors

Masters

Major

Minor

College/University

Graduation Date (Month/YR)

Did not graduate

Did not Graduate

Degree Type

Bachelors

Masters

Major

Minor

Please describe any relevant experience you have working and/or interacting with children and/or adults with developmental disabilities:(Required)

Why are you interested in working with individuals with developmental disabilities?(Required)

Are you comfortable working with participants who may require personal care &/or hygiene assistance? *Additional training provided(Required)

Yes

Please Explain(Required)

Are you comfortable working with participants who may exhibit occasional physical aggression? *Additional training provided(Required)

Yes

Please Explain(Required)

Previous Employment

List all current and former employers, beginning with your current or most recent employer. Click the “+” icon to add more employers.

List(Required)

Company

Phone

Address

Supervisor

Job Title

Starting Pay

Ending Pay

Responsibilities

Dates of Employment

Reason For Leaving

May we contact your previous supervisor for a reference?

References

Please list two professional or personal references. Click the “+” icon to add more references.

References(Required)

Full Name

Relationship

Company

Phone

Address

Number of Years Known

References(Required)

Full Name

Relationship

Company

Phone

Address

Number of Years Known

Employment Desired

Position Applying For(Required)

Are you available Full Time or Part Time?(Required)

Full Time

Part Time

Desire Full Time but will accept Part Time?(Required)

Yes

Date Available(Required)

Desired Pay Range(Required)

Number of hours per week requested (i.e. 20 – 60 hours)(Required)

Hours Available

List the Hours You Are AVAILABLE to Work:

Monday(Required)

Tuesday(Required)

Wednesday(Required)

Thursday(Required)

Friday(Required)

Saturday(Required)

Sunday(Required)

Hours Unavailable

List the Hours You ARE NOT AVAILABLE to Work:

Monday(Required)

Tuesday(Required)

Wednesday(Required)

Thursday(Required)

Friday(Required)

Saturday(Required)

Sunday(Required)

Are there any upcoming changes to your schedule that will affect your availability in the next 3 months(Required)

(i.e., starting or finishing school, travel, etc.)?

Yes

Please Describe(Required)

Legal

State of Idaho regulations require a criminal, employment, and personal background check on all new employees. The following questions below are taken directly from the Idaho State Background Check Application.

Have you ever been arrested or, received a citation for any misdemeanor or felony offense (including a DUI or DWI) in Idaho or any other state?(Required)

This includes any prior or current misdemeanor or felony charges, arrests, or convictions (even if juvenile, dismissed, or resulted in withheld judgment).

Yes

List date(s), the specific charge(s), and explain:(Required)

Have you ever been convicted of a misdemeanor or felony offense in Idaho or any other state?(Required)

This includes any prior or current misdemeanor or felony convictions (even if juvenile, dismissed, or resulted in withheld judgment).

Yes

List date(s), the specific charge(s), and explain:(Required)

Have you ever been the subject of a Child or Adult Protection Action or investigation that was substantiated in Idaho or any other state?(Required)

Yes

List date(s), the specific charge(s), and explain:(Required)

Are you currently under investigation for a crime or awaiting a judgment in Idaho or any other state?(Required)

Yes

List date(s), the specific charge(s), and explain:(Required)

Travel / Vehicle Use

Are you willing to use your personal vehicle to transport participants in and around the community?(Required)

Yes

What areas are you willing to travel to/work in?(Required)

(Check all that apply.)

Coeur d’Alene

Post Falls

Hayden

Athol / North Pole

Kellogg / Mullan

Plummer / St. Maries

Dalton Gardens

Rathdrum / Spirit Lake

Bonners Ferry / Moyie Springs

Ponderay / Sandpoint / Priest River

Certifications and Relevant Experience

Adult Developmental Therapy(Required)

Yes

Adult Developmental Specialist(Required)

Yes

Clinical Supervisor / Hab Intervention Certified(Required)

Yes

Habilitative Supports / Children’s DT(Required)

Yes

Behavior Intervention / IBI(Required)

Yes

Certified Nursing Assistant(Required)

Yes

Caregiver(Required)

Yes

Mental Health Services(Required)

Yes

Employment Specialist(Required)

Yes

Job Coaching / Work Services(Required)

Yes

Mandt / Restraint Certified(Required)

Yes

Residential Habilitation / Supported Living(Required)

Yes

Signing – American Sign Language(Required)

Yes

Signing – Finger Spelling(Required)

Yes

Targeted Service Coordinator(Required)

Yes

Other (list):

Do you speak a foreign language?(Required)

Yes

Please List:(Required)

Are you interested in other CCI positions?(Required)

Yes

Please List:(Required)

Certification

I certify that the statements and information furnished by me in this application are true and correct to the best of my knowledge. I understand that any false information on this application is grounds for refusal to hire and, if employed, will be cause for immediate dismissal at any time CCI becomes aware of the falsified information.
I understand that, with my authorization, an investigation may be made whereby information is obtained regarding my character, previous employment, general reputation, educational background, and criminal history, subject to applicable Federal, State, and/or Local laws.
I understand and agree that if employed, the employment will be “at will”. That is, either I or CCI may end the employment relationship at any time, for any reason, or for no reason. I understand that receipt of this application by CCI does not imply employment and that this application and/or any other CCI documents are not contracts of employment.
I understand that CCI is a drug free workplace and that I am subject to drug testing per reasonable suspicion.
My signature certifies that I have read and agree with the above statements.

I agree

Signature(Required)

Date(Required)

MM slash DD slash YYYY