Employment ApplicationPlease enable JavaScript in your browser to complete this form.APPLICANT INFORMATION:Name *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Authorization to text *Yes, I give UCP permission to text me regarding my application and next steps in the hiring process.No, please do not text me.Email *Are there other names under which you have worked or attended school? *YesNoIf yes, please list for reference checking purposes:EMPLOYMENT OBJECTIVE:Position Desired: *Inclusion FacilitatorRespite ProviderSupport SpecialistNo PreferenceHow did you learn about the position?Date Available to Begin Employment:How many hours do you want to work per week?Are you applying to work with a specific person?NoYesWho?What is your relationship?Are you interested in working with additional families?YesNoGENERAL INFORMATION:Are you legally authorized to work in the U.S.?YesNoChoice 3(If hired, you will be required to provide proof of work authorization.)Are you age 18 or older?YesNoFor positions where a vehicle is required:I have access to a reliable vehicle.I have a valid driver's license.I prefer to be placed on the busline.(Please check all that apply.)Have you ever been convicted of a felony, misdemeanor or other offense (other than minor traffic offenses), or have any pending charges?YesNoIf yes, please explain the nature of the offense, date of conviction and state in which you were convicted:(Note: Each circumstance will be judged in relation to time, seriousness and relationship to the job for which you are applying and will not necessarily bar you from employment.)AVAILABILITY:Please indicate the times you are interested in working by entering the exact times you are available to work each day:Sunday:Monday:Tuesday:Wednesday:Thursday:Friday:Saturday:Please share any additional, relevant information regarding your availability:Please indicate which communities you are open to providing services in:AllBlack EarthBrooklynCottage GroveCross PlainsDeForestEdgertonFitchburgMadison - ALLMadison - EastMadison - CentralMadison - WestMarshallMazomanieMcFarlandMiddletonMononaMount HorebOregonStoughtonSun PrairieVeronaWaunakee(Please select all that apply.)Please indicate the environments you would like to provide services:Community-basedIn a family's homeIn your home(You may select more than one.)Do you have any allergies that prevent you from working in certain environments?YesNoIf yes, please explain:EXPERIENCE AND INTERESTS:Do you have experience working with people who have disabilities?YesNoDo you have experience assisting with personal care needs?Yes, and I am comfortable doing this.I do not have experience but with training I think I would be comfortable.I am not comfortable assisting with personal care needs.(feeding, bathrooming, dressing, etc.)Do you have experience supporting challenging behaviors?Yes, and I am comfortable doing this.I do not have experience but with training I think I would be comfortable.I am not comfortable supporting challenging behaviors.(hitting, kicking, biting, etc.)Which age group are you most interested in working with?Early Childhood (0-4)School Aged Children (5-12)Teenagers (13-18)Yount Adults (19-25)Adults (26+)(Please check all that apply.)Are you comfortable working with children or adults who use a wheelchair or other assistive equipment to help with mobility?YesNoHow many pounds are you safely able to lift?EDUCATION:What is the highest level of education you have completed?Some high school, no diplomaHigh school graduate or equivalentSome college credit, no degreeTrade/technical/vocational trainingAssociate DegreeBachelor's degreeMaster's degreeAdditional coursework beyond Master's degreeAdditional relevant information regarding your education:(Major, minor, relevant coursework, etc.)EMPLOYMENT HISTORY:I have no prior employment history.Name of Employer:Please start with your most recent position. Please include all previous work experiences, including military service and significant volunteer activities.Position:Address:Date of Hire:Last Date Worked:Please list the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company.Reason for leaving:Name of Supervisor:Phone:Email:May we contact this person as a reference?YesNoIf no, please provide us the name, contact information and relationship of another person we may contact:Do you have additional employers to list?YesNoName of Employer:Position:Address:Date of Hire:Last Date Worked:Please list the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company.Reason for leaving:Name of Supervisor:Phone:Email:May we contact this person as a reference?YesNoIf no, please provide us the name, contact information and relationship of another person we may contact:Do you have additional employers to list?YesNoName of Employer:Position:Address:Date of Hire:Last Date Worked:Please list the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company.Reason for leaving:Name of Supervisor:Phone:Email:May we contact this person as a reference?YesNoIf no, please provide us the name, contact information and relationship of another person we may contact:ADDITIONAL REFERENCES:Please list any other supervisory references or individuals familiar with your job qualifications (Please do not list relatives or friends.)Reference 1:Name and Relationship:Organization:Email:Phone:Reference 2:Name and Relationship:Organization:Email:Phone:Reference 3:Name and Relationship:Organization:Email:Phone:Please list any additional experiences, training or education which you feel is relevant to becoming an Inclusion Facilitator or Respite Provider. This may include personal experiences supporting people with disabilities, course work, other languages, licenses, certifications, volunteer work, civic duty, etc.All information contained in this application is true and complete to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired. I authorize investigation of all statements in this application and contact of any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment. Regardless of whether or not I become employed by the organization, I recognize that this application is not and should not be considered a contract of employment. I understand that employment at the organization is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the organization's, unless specifically provided otherwise in a written employment contract. I further understand that no organization employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the organization *I agree.EmailSubmit