Personal Care Worker Application

If you are having trouble submitting this form please call (724) 652-5144.

County *

First Name*

Last Name *

Email Address *

Address 1 *

Address 2

City, State, Zip Code *

Phone Number *

Were you 18 years of age or older on your last birthday?: *
YesNo

Do you have a valid driver's license?: *
YesNo

Do you have a car for work use?: *
YesNo

If you answered no to either of the last two questions, will you be able to arrange for independent travel?:
YesNo

Are you willing to undergo a criminal records and child abuse check as part of this application process?: *
YesNo

Do you have experience in or are willing to do the following?:

Feeding: *
YesNo

Bathing: *
YesNo

Dressing/Undressing: *
YesNo

Laundry: *
YesNo

Shaving/Makeup: *
YesNo

Shampooing: *
YesNo

Toilet Care: *
YesNo

Bowel and Bladder Care: *
YesNo

Transferring: *
YesNo

Meal Preparation: *
YesNo

Light Housekeeping: *
YesNo

Do you have experience working with individuals with Intellectual Disabilities and/or Autism? *
YesNo

Upload your resume (pdf only):