Application Form

We are excited you are considering SYNERGY HomeCare for employment.  If you are choosen to become a member of our CareTEAM, you will join a fanastic group of caregivers dedicated to helping seniors and disabled adults live independent and fulfilliing lives.  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

Section 1 - General

Section 2 - Availability

Section 3 - Personal and Employment References

Section 4 - Acceptance of Term & Conditions

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 gifts 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, perform medical procedures,
Render an opinion on behalf of Synergy HomeCare on the client’s medical situation, financial statements, or sign my name to any tax 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 or a guarantee of any amount of work hours;
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 two weeks 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 Synergy client;  I will never disclose any Synergy client's personal health information.
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.  I will use my personal smartphone to clock in and out of my employment assignments.  I will keep all my login information confidential.
         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.
         11.  If it is determined that I inappropriately took monies from a Synergy client, I agree that Synergy has the right to remove equal amounts from my paycheck(s).
         12.  I understand I will be asked to sign a Mutual Dispute Resolution and Arbitration Agreement that commits me to a Internal Resolution Period and arbitration process, if necessary to resolve employment issues.  I agree to using arbitration to resolve any employment issues with Synergy.  I agree not to bring a class action lawsuit against Synergy.

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.  SYNERGY CareTEAM - Together We Change Lives!