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Position & Availability
Position Applied For (select all that apply):
(Required)
Personal Support Worker (PSW)
Developmental Support Worker (DSW)
Health Care Aide (HCA)
Employment Type (select one):
(Required)
Full-Time
Part-Time
Relief / Casual
Preferred Work Setting (select all that apply):
(Required)
Group Home / Residential
Supported Living / Host Family
Community / Day Programs
In-Home Supports
Respite (In‑Home or Out‑of‑Home)
Availability (select all that apply):
(Required)
Days
Evenings
Nights
Weekends
Statutory Holidays
Flexible / Rotational
Personal Information
Full Legal Name:
(Required)
Preferred Name (if different):
Phone Number:
(Required)
Email Address:
(Required)
City/Town:
(Required)
Province:
(Required)
Are you legally entitled to work in Canada?
(Required)
Yes
No
Education & Training
Highest Level of Education Completed:
(Required)
High School
College Diploma
University Degree
Other
If Other Please Specify
Relevant Certification(s) (select all that apply):
(Required)
Personal Support Worker (PSW)
Developmental Support Worker (DSW)
Health Care Aide (HCA)
Disability Studies
Nursing / Health Sciences
Other
If Other Please Specify
Institution(s) Attended & Year Completed:
(Required)
Professional Experience
Do you have experience working with individuals with disabilities?
(Required)
Yes
No
If yes, please indicate areas of experience (select all that apply):
(Required)
Developmental Disabilities
Dual Diagnosis
Physical Disabilities
Mental Health
Autism Spectrum Disorder
Complex Needs / High Behaviour
Seniors Care
Years of Relevant Experience:
(Required)
Less than 1 year
1–3 years
3–5 years
5+ years
Briefly describe your relevant work experience:
Skills & Competencies
Please select all that apply:
Personal Care (bathing, grooming, toileting)
Medication Assistance / Administration
Behavioural Support Strategies
Community Access & Inclusion
Meal Preparation & Nutrition Support
Mobility & Transfers
Documentation & Progress Notes
Crisis Prevention / De‑escalation
Household Management
Mandatory & Compliance Requirements
Criminal Record / Vulnerable Sector Check:
(Required)
Current (within last 6 months)
Willing to obtain
Not available
First Aid & CPR Certification:
(Required)
Current
Expired
Willing to obtain
Medication Training (if applicable):
Completed
Willing to complete
Immunizations (as per public health requirements):
(Required)
Up to date
In progress
Willing to comply
Transportation & Practical Considerations
Do you have a valid driver’s licence?
(Required)
Yes
No
Do you have access to a reliable vehicle?
(Required)
Yes
No
Are you willing to travel between locations?
(Required)
Yes
No
Professional Suitability
Please answer briefly:
Why are you interested in this role?
(Required)
Describe your approach to supporting individuals with diverse needs.
(Required)
How do you maintain professionalism and boundaries in care relationships?
(Required)
References
Please provide two professional references:
Reference 1 Name:
(Required)
Relationship:
(Required)
Phone / Email:
(Required)
Reference 2 Name:
(Required)
Relationship:
(Required)
Phone / Email:
(Required)
Declaration
Consent
(Required)
I agree to the privacy policy.
I certify that the information provided in this application is true and
complete to the best of my knowledge. I understand that false
information may result in disqualification or termination of employment.
Applicant Name:
(Required)
Date:
(Required)
MM slash DD slash YYYY
Submission of this application does not guarantee employment. Short‑listed candidates may be contacted for an interview and further screening.
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