Apply for Part-time Individual Family Support Respite Provider

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Contact Information
* First Name:
* Last Name:
Former or Maiden last name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* Social Security Number:
We use your SSN for verification on the Health Care Worker Registry.
Attachments
Please upload your resume.
Resume:
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Cover Letter:
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Application
We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on the basis prohibited by local, state or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.
All candidates who are offered a position will be required to authorize DSC to conduct a criminal background check pursuant to the IL Healthcare Worker Background Check Act.
Further, DSC is prohibited from making an offer of employment until an individual has been screened as required by Illinois laws and regulations for a past history of abuse and neglect.
Bus/CDL drivers and those filling safety sensitive positions will be required to undergo pre-employment drug screening and submit to random drug and alcohol testing as part of their continued employment pursuant to the Department of Transportation regulations.
General Questions
Yes   No
*
Yes   No
EDUCATION/SKILLS

High School

Yes   No

College

1   2   3   4
Yes   No
REFERENCES

Please list 3 professional references.

Reference 1

*
*
*
*

Reference 2

*
*
*
*

Reference 3

*
*
*
*
REMARKS
I hereby authorize DSC to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability DSC and its representatives for seeking, gathering, and using work-related information to make employment decisions and all other persons or organizations for providing such information. This does not release any parties from liability for seeking or releasing information which is prohibited under any anti-discrimination laws.
I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.
If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either DSC or I can terminate the relationship at will, with or without cause, at any time, so long as there is not violation of applicable federal or state law.
I understand that it is the policy of DSC not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.
I also understand that if I am offered employment, I will be required to provide satisfactory proof of identity and legal work authorization.
I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.
Important notice to Applicant about prior criminal convictions
IMPORTANT NOTICE TO APPLICANT ABOUT PRIOR CRIMINAL CONVICTIONS
DSC is a healthcare employer as defined in the Healthcare Worker Background Check Act and, as such, we cannot knowingly employ or retain any individual, if that person has been convicted of committing or of attempting to commit one or more of the offenses enumerated here. An offer of employment by this facility, then, is conditioned upon a finding of no prior criminal convictions in the areas covered by the Illinois Healthcare Worker Background Check Act. Please read and initial the following statements:
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DSC will obtain a fingerprint based criminal background check prior to offering you regular employment.
*
DSC will not hire you, if the fingerprint based background check shows that you have been convicted of committing or attempting to commit one or more of the offenses listed below.
*
Individuals may request a waiver, if an adverse report is received, as well as challenge its completeness and accuracy.
*
If the waiver of the prohibition against employment is granted, DSC has the option, but not the obligation, to hire you.
ACKNOWLEDGMENT
Applicant hereby acknowledges, by his or her signature below, that the foregoing NOTICE TO APPLICANT has been explained by the facility, and applicant has indicated an understanding of the foregoing with his or her initials, and applicant agrees to cooperate with the criminal background check procedure and is aware that if the check results are adverse, facility has the right not to offer regular employment, even if a waiver is granted:

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