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Raising the standard in senior care.

About Us
Our Services
Community Life
Guided Solutions
Careers
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About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

Schedule a Tour

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

Schedule a Tour

Raising the standard in senior care.

Schedule a Tour

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

Schedule a Tour

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

×

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

Let's Start the Conversation

We're here when you're ready.

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Schedule Your Senior Care Consultation

750 NW Walnut Lane
Topeka, KS 66617
(785) 496-9969

Lisa Chamberlain, Owner/Operator

Tammy Willits, Owner/Operator

Jodi Broxterman, RN

(785) 496-9951

administrator@keeplivinghp.com
Open 24/7

"*" indicates required fields

Name of Person That Will Tour*

Phone Number*

Email*

Name of Potential Resident*

Message*

Name

This field is for validation purposes and should be left unchanged.

🏠 Keep Living Home Plus – Employment Application

Thank you for your interest in joining our team! We are committed to providing the highest quality of care to our residents, and we’re excited to learn more about you.

🔹 Personal Information

Full Name:

Date of Birth:

MM slash DD slash YYYY

Phone Number:

Email Address:

Current Address:

Street Address City State / Province / Region ZIP / Postal Code Country

🔹 Position Applied For

Position Applied For

CNA (Certified Nurse Aide)

HHA (Home Health Aide)

CMA (Certified Medication Aide)

LPN (Licensed Practical Nurse)

RN (Registered Nurse)

Other

Other:

🔹 Certifications & Licenses

Please check all that apply and provide license numbers where applicable:

Add Certification Type Below

CNA | HHA | CMA | LPN | RN

Certifications & Licenses

Certification Type

State

License Number

Expiration Date

🔹 Employment History (List your most recent 3 employers)

Employer 1

Employer Name:

Position Held:

Start Date:

MM slash DD slash YYYY

End Date:

MM slash DD slash YYYY

Supervisor Name:

Phone Number:

Reason for Leaving:

Employer 2

Employer Name:

Position Held:

Start Date:

MM slash DD slash YYYY

End Date:

MM slash DD slash YYYY

Supervisor Name:

Phone Number:

Reason for Leaving:

Employer 3

Employer Name:

Position Held:

Start Date:

MM slash DD slash YYYY

End Date:

MM slash DD slash YYYY

Supervisor Name:

Phone Number:

Reason for Leaving:

🔹 References

Professional Reference #1

Full Name:

Relationship:

Phone Number:

Professional Reference #2

Full Name:

Relationship:

Phone Number:

Personal Reference

Full Name:

Relationship:

Phone Number:

🔹 Availability

What days are you available to work?

Are you available for:

Days

Evenings

Weekends

Overnights

Can you work holidays?

Yes

No

🔹 Background Check Authorization

Background Check Authorization

I hereby authorize Keep Living Home Plus and its representatives to conduct a background check and investigate all statements contained in this application. I release all parties from any liability arising from such investigations. I understand that any false or misleading information provided may result in my disqualification or termination if already employed.

Signature:

Date:

MM slash DD slash YYYY

Raising the standard in senior care.

Schedule a Tour

750 NW Walnut Lane
Topeka, KS 66617
(785) 496-9969
(785) 496-9951
administrator@keeplivinghp.com

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