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  • Trainee Application for Employment

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    • For Office Use Only

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    • Personal Information

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    • Availability

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    • Interview

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    • {firstName}, Please complete the application below

    • Education & Employment History

    • List below your previous employer(s), starting with the last one.

    • W4 & I9

    • Legal and Background Check

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    • **Sorry, we cannot accept your application at this time. Please start your application over again**

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    • Heart to Heart Home Care Agency/Training Program is required to submit certain information on each aide/trainee to be included in the HCR. This information includes name (current and previously used), date of birth, current home address, gender, information on the training program and employment information.

      Heart to Heart Home Care Training Program must verify and document the trainee’s identify by examining an unexpired, approved document containing the trainee’s photograph. If the trainee fails to provide one of the specific documents, the training program must deny
      participation in the program.

         Heart to Heart Home Care Agency/Training Program also must obtain consent to utilize the last four (4) digits of the trainee/aide’s social security in the HCR process or identify three (3) security questions to be utilized in place of the last four (4) digits. Please indicate which option you prefer:

          I give consent to Heart to Heart Home Care Agency/Training Program to utilize the last four (4) digits of my social security number in the HCR process. 
        Utilize three (security questions from the HCR)
      *   Utilize the following three (3) security questions for the HCR process:
      1. Mother’s Maiden Name:      
      2. City of Birth:          
      3. Mother’s First Name:      

    • 1. Mother’s Maiden Name:   *   
      2. City of Birth:   *       
      3. Mother’s First Name:   *   

    • Benefits & Compensation

    • Health Questionnaire

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    • Government Assistance

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    • Urban Youth Section 

    • New York Urban Youth Jobs Program

    • New York Youth Jobs Program: Youth Certification Qualifications:

      To participate in the New York Youth Jobs Program:

      • You must be 16 to 24 years old, and
      • You must live in one of the target areas of New York State listed in item nine on page one, and You must be unemployed, and
      • At least one of the following statements must apply to you:
        • I am over 18 years of age and do not have a high school diploma or a General Educational
        • Development (GED) or High School Equivalency (HSE) diploma.I am a member of a family that is receiving:
          • Assistance from Temporary Assistance for Needy Families (TANF).
          • Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps).
          • Social Security Income (SSI) benefits.
        • I am receiving a free or reduced-cost school lunch.
        • I was referred to this program by a rehabilitation agency approved by the state, or anemployment network under the Ticket to Work Program.
        • I have served time in jail or prison or I am on probation or parole.
        • I am pregnant or a parent.
        • I am homeless.
        • I am currently or was in foster care or the custody of the Office of Children and Family Services.
        • I am a veteran.
        • I am the daughter or son of a parent who is currently in jail or prison, or was in jail or prison withinthe past two years.
        • I am the daughter or son of a parent who is collecting unemployment insurance.
        • I live in public housing or receive housing assistance such as a Section 8 voucher.
        • I have another risk factor not identified above

    • Are any of the following statements true:

      • I am currently unemployed
      • I was unemployed prior to completing this application
      • I do not have enough paid work
      • The work I have does not make sure of my skills and training

         *         

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    • Signature

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    • Pay Rate 
    • W4 
    • IT 2104 
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    • I9 
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    • 8850 
    • Important Calculations 
    • Urban Youth Hidden Mapped Fields 
    • CHRC 
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    • ACA Benefit Form 
    • Hidden Mapped Fields 
      • Weakness
      • Unexplained Fatigue for more than 3 weeks
      • Lack of Appetite
      • Unexplained Weight Loss
      • Low Grade Fever
      • Unexplained Fever, Chills, or Drenching Night Sweats
      • Persistent Shortness of Breath
      • Persistent cough for more than 3 weeks
      • Blood streaked sputum
      • Clear, Yellow, or Dark Sputum
      • Coughing Up Blood
      • Chest Pain
      • Have you ever been diagnosed with active TB disease?
      • Have you been treated with medication for TB or for a positive TB test?
      • Have you ever been diagnosed with latent TB infection or had a positive skin test or a positive blood test for TB? Have you ever lived in a country with a high TB rate?
      • Is your immune system compromised due to a virus or medication? Have you recently had close contact with someone who has had TB disease?
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    • waiver 
    • Clear

    • Quiz

      • I am over 18 and do not have a high school diploma of GED/HSE diploma.
      • I am a member of a family that is receiving assistance from TANF.
      • I am a member of a family that is receiving SNAP benefits (food stamps).
      • I am a member of a family that is receiving SSI benefits.
      • I am receiving a free of reduced-cost school lunch.
      • I have served in jail or prison, or am on probation or parole.
      • I am pregnant or a parent.
      • I am currently or was in foster care of the custody of the Office of Children and Family Services.
      • I am a veteran.
      • I am the daughter or son of a parent who is currently in jail or prison, or has been within in the past two years.
      • I am the daughter or son of a parent who is collecting unemployment insurance.
      • I live in public housing or receive housing assistance such as a Section 8 voucher, or is homeless.
      • Another risk factor not identified above


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    • References

    • Medical Benefits

    • If you are declining enrollment for yourself because of other healthcare coverage, you may enroll yourself prior to the next enrollment period. To do this, you must have involuntarily lost your other coverage and we must receive your enrollment application within 30 days after your other coverage ended.

      Any person who knowingly and with intent to defraud any insurance company or other persons files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to exceed $5,000 dollars and the stated value of the claim for each violation. Any material misrepresentation within this waiver may subject the group to termination.

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