* = Required Information
Personal Information
Yes No
Yes No
Emergency Contact
Transportation
Yes No
Yes No
Legal Record
Yes No
Yes No
Referral Information
References
Three professional references required.
Education
Home Care Aide Registration
Yes No
Yes No
Employment History
Yes No
Experience
Availability
Am Pm Graveyard Live-In
Am Pm Graveyard Live-In
Please indicate the days and time you are available to work:







Yes No



I, (name of health care provider), wish to provide private duty services to one or more clients of Abba In-Home Care Services, LLC.

Abba In-Home Care Services, LLC reserves the right to change the contents of this Manual at any time. No changes in any benefit, policy or rule will be made without due consideration to the effect such changes will have on you as an employee and on Abba In-Home Care Services, LLC.

I acknowledge receipt and have read the Manual. I understand the policies, rules and benefits described within this Manual and acknowledge that Abba In-Home Care Services, LLC reserves the right to change the contents of this Manual at its discretion.

I acknowledge that my employment may be terminated "at will", either by myself or Abba In-Home Care Services, LLC regardless of length of employment. I acknowledge that no contract of employment, other than "at will" has been expressed or implied and that no circumstances arising out of my employment will alter my "at will" employment relationship unless expressed in writing.

I acknowledge that during my course of employment with Abba In-Home Care Services, LLC , confidential information may be made available to me and this information will not be disclosed or used outside of the scope of my position at Abba In-Home Care Services, LLC I acknowledge the policies, procedures; rules and benefits set forth in this Manual revoke all previous inconsistent policies and procedures for Abba In-Home Care Services, LLC as of the effective date of this Manual. I also acknowledge it is my responsibility to be familiar with these policies and any changes or modifications thereto. My signature below acknowledges that I have read the above statements and received a copy of the Abba In-Home Care Services, LLC Employee Policy Manual.
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