Date: 5/28/2016

Application Form

Synergy HomeCare NW Houston

SYNERGY HomeCare is an equal opportunity employer and is dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
Home Phone * Zip *
Work Phone Driver's License Number
Mobile Phone
Email *

Section 1 - Minimum Requirements

Number Question Effective Date Expiration Date
2 Are you 21 years of age or older? (required)  
3 Please provide us your date of birth (held in strict confidence). (required)  
5 Are you legally authorized to work in the United States? (required)  
6 Do you have a valid Driver's License (not an identification card)? (required)  
7 Do you have a reliable vehicle which is in good working condition that you can use without restrictions? (required)  
8 Do you have valid liability insurance on your vehicle naming you as an insured driver? (required)  
9 Do you have a cell phone that you own and is reliable and consistently available to you? (required)  
10 Do you have a cell phone that allows you to accept emails and text messages? (required)  
11 Please provide us the name of the company that is your cell phone carrier/provider. (required)  
13 Our office staff will text your cell phone with various notifications. Does your cell phone allow text messages? (required)  
16 If you are a MA, CNA, LVN, or RN has your professional license ever been investigated or suspended? If "Yes", please explain. (required)  
17 Are you willing to consent to a thorough background check and pre-employment drug test? (required)  

Section 2 - Experience

Number Question Effective Date Expiration Date
1 Do you have previous experience caring for seniors or disabled persons? (required)  
2 How many months/years of caregiving experience do you have? (required)  
3 What type of prior caregiving experience do you have? (required)  
5 Please check any licenses or certifications you currently hold. (required)  
6 What is the last level of education you have completed? (required)  
9 Please indicate which, if any, Synergy office for which you have previously worked or applied . (required)  

Section 3 - Skills (Please check all you have EXPERIENCE in)

Number Question Effective Date Expiration Date
1 Alzheimer's / Dementia Care (required)  
2 Personal Care: Bathing, Showering, Dressing, Transferring, Mobility Assist, Toilet Assist, Incontinence (Diapers) Care, Personal Hygiene (required)  
3 Live-In Care (spend 2 to 4 days residing with client) (required)  
10 Gait Belt (required)  
11 Hoyer Lift (required)  
12 Transportation / Errands (required)  
13 Meal Preparation / Meal Planning (required)  
14 Light Housekeeping (required)  
15 Pediatric Care / Special Needs Child Care (required)  
18 G-Tube (cleaning and feeding on machine) (required)  
19 How many months/years experience transferring individuals from bed/chair to a wheelchair/toilet (or vice versa) do you have? (required)  
21 Can you transfer someone weighing greater than 150 lbs? (required)  
22 Can you lift 35 lbs consistently without pain, soreness or hesitation? If not, please explain. (required)  
23 Do you have any physical limitations or medical condition(s) that would prohibit you from lifting, rolling or transferring a person or performing any other typical home care duties? (required)  

Section 4 - Availability

Number Question Effective Date Expiration Date
1 Are you currently employed? If so, can we contact your current employer? (required)  
2 If you are not employed, please tell us the reason for you unemployment (if employed, please indicate "N/A"). (required)  
3 If unemployed, how long have you been without a job? (required)  
6 Whether employed or unemployed, tell us why you left your last job. (required)  
8 Please tell us the days and times you are available to work for Synergy. Please go into detail. (required)  
9 Are you available for 12-hour or 24-hour shifts? (required)  
10 Are you available for Live-In or 24/7 assignments? (required)  
16 What is the best time for one of our office staff to call and speak with you? (required)  
17 You will be asked to work throughout north Greater Houston--including: Spring, Tomball, Cypress, The Woodlands, Cy-Fair, Spring Branch, Heights, Champions, Copperfield, Crosby). Do you accept this requirement of employment? (required)  

Section 5 - Caregiver Qualities

Number Question Effective Date Expiration Date
1 Tell us why you want to work in the senior home care industry? (required)  
3 Can you speak more than one language fluently? If so, which language (besides English) are you fluent in? (required)  
4 Would you be willing to accept an emergency / fill-in assignment for a client on a short-notice basis? (required)  
5 Please tell us your opinion: In the home care business, it is ok to be a little late to assignments. (required)  
6 Tell us why you would be an asset to Synergy. (required)  
7 Have you ever been released from a job due to disciplinary actions or being fired? (If "Yes", please explain.) (required)  
8 Are you able to work with cats? (required)  
9 Are you able to work with dogs? (required)  
10 Do you smoke? (We ask this to ensure proper match with Client preferences.) (required)  
11 Are you willing to accept work with a client that smokes? (required)  
12 Synergy requires applicants to complete an online training program before you are asked to come for Orientation. Do you accept this requirement? (required)  

Section 6 - Personal and Employment References

Number Question Effective Date Expiration Date
1 Personal Reference #1: Please provide full name, phone number, and relationship to you: (required)  
2 Personal Reference #2: Please provide full name, phone number, and relationship to you: (required)  
4 Employment Reference #1: Please provide company name/employer, full name of supervisor, supervisor's phone number, dates of employment, pay rates, and reason for leaving: (required)  
5 Employment Reference #2: Please provide company name/employer, full name of supervisor, supervisor's phone number, dates of employment, pay rates, and reason for leaving: (required)  
7 Please provide us an emergency contact: full name, relationship and phone number.  

Section 7 - Employment Process

Number Question Effective Date Expiration Date
1 How did you find out about Synergy HomeCare? (required)  
2 Can you work in the Brenham or College Station areas? (required)  
3 Are you willing to consent to background check and drug screening for continued employment? (required)  
5 If you have not heard from us within 2 business days of applying, please call 281-999-2273 to ask about the status of your application.  

To complete your application, you must read the information below AND click the SUBMIT APPLICATION button at the end of this form.  I understand and agree that by hitting the "Submit Application" button below that I have read, understand and will comply with all rules and procedures stated below.

I certify that information contained in this application is true, correct and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future. If employed by Synergy HomeCare, I will comply with all rules and regulations of the company. I agree to submit to any physical or drug examination if requested. I authorize my former and current employers to give any information they have regarding me to Synergy--whether or not it is in their employment records. I also authorize Synergy to conduct any background checks necessary including, but not limited to: felony/misdemeanor convictions, previous arrest history, and driving records. I release all parties (including Synergy) from any and all liability and damage for issuing or procuring the same. I understand that if any fraudulent information is given on this application, it will be grounds for immediate termination. Synergy HomeCare is an Equal Opportunity Employer. I understand that Synergy's job positions are placed equally without discrimination because of race, creed, color, religion, sex, national origin, sexual preference, handicap, or age.


This agreement is between Synergy HomeCare and the applicant in which Synergy HomeCare and applicant agree to the following:

          1.  I understand while I am a caregiver on assignment, I am an employee of Synergy HomeCare and will never give my personal phone number to a client or client representative nor will I accept any money or gift from Synergy HomeCare clients or client representatives;

           2.  While I am a caregiver on assignment, I am an employee of Synergy HomeCare and I am not authorized to:
                          ·        Operate the client’s machinery (except standard office equipment), stand on ladders, administer any medication,
Render an opinion on behalf of Synergy HomeCare on the client’s financial statements, or sign my name to any fax returns,
Handle cash, negotiable instruments (including checks, money orders and gift cards) or other valuables without written permission from Synergy or may not transport or convey monies, securities or any negotiable instruments (including, but not limited to, delivering bank deposits to bank or other financial institution.)

I understand that applying / registering with Synergy HomeCare is not a guarantee of employment.;
I can thoroughly and consistently perform all job duties (including lifting 35 pounds) without injury or concern;
           5.  I
will notify Synergy HomeCare of any event that may prevent me from accepting or completing an assignment.  If I am unable to complete my assignment, I will give Synergy HomeCare a minimum of one (1) week notice.  I understand that if I do not report to an assignment and I do not contact Synergy HomeCare prior to the assignment start time, Synergy HomeCare may assume that I have voluntarily quit and I will no longer be eligible to work through or be represented by Synergy HomeCare;
Synergy HomeCare may provide me with opportunities and or job interviews in my field of caregiving.  Synergy HomeCare shall, at its own expense, spend time and effort researching the job market and contacting potential clients, which efforts may result in resume presentation and or job interviews.  In consideration for the services provided above, I agree that I will not directly solicit or seek employment from any individual or any contact associated with or referred by same, with whom Synergy HomeCare presents my resume to and/or arranges an interview with, and/or places me on assignment with, now or at any time during the twelve (12) months following my resume presentation, interview or assignment or twelve (12) following my voluntary termination or discharge from employment.  I understand if I do solicit and/or accept employment with any potential  or current client/employers in which Synergy HomeCare has within twelve (12) months of resume presentation, interview or assignment and do accept employment as either a permanent, contract or temporary position, a Referral/Employment Fee will be required to be paid to Synergy HomeCare by me.  This Referral/Employment Fee will be equal to the average monthly pay over the previous 3 months of my employment with that particular client or $2000 whichever is the greater amount. If I accept monies from any current or former Synergy HomeCare client, Synergy HomeCare may conclude that a Referral/Employment Fee is required to be paid by me.

Our employees are often placed in positions where they are required to handle information or work with procedures that are proprietary to our clients.  Therefore, the applicant agrees to the following:

          7.  I understand the information I come in contact with is confidential and proprietary;
I will not at any time during my employment or any time thereafter publish, disclose, or utilize any confidential or proprietary information and material gained while working as an employee with any client;
I will protect the integrity of written records by storing and working with them in an appropriate manner, I will not copy any documents or portion of any document without specific instructions to do so.
         10.  I
understand that as an employee of Synergy HomeCare I may be sent on assignments to clients that may have been previously serviced directly or indirectly by competitors of Synergy HomeCare.  I will not disclose details of my work, pay, or other Synergy information with any client or other home care or home health company representative.

I have read, understand and agree with the Terms and Conditions and Non-Compete Agreement stated here.  I understand that they are applicable at all times while I am employed by or represented by SYNERGY HomeCare.  I will fully comply with these rules and requirements.  Failure to do so may result in my immediate termination or removal from client assignments.  I understand and agree that by hitting the "Submit Application" button below that I have read, understand and will comply with all rules and procedures stated in this application.