1 Employment Application High Desert Assisted Living-Houses 1 & 2
House 1:
House 2:
* = required
APPLICATION INFORMATION
Last Name
First
M. I.
Date of Application
Street
Apt / Unit #
City
State
ZIP
Home Phone
Cell Phone
Email Address
† Home Phone or Cell Phone — at least one is required.
Position Applied for
SSN
Date Available
Desired Hourly Rate$ /hr
Emergency Contact Name
Relationship
Phone #
Marital Status
DOB
Are you a citizen of the United States?
If no, are you authorized to work in the US?
Have you ever been convicted of a felony?
If yes, please explain:
Do you have current (or past) injuries that may prevent you from performing the duties required of this position?
If yes, please explain:
Worker's Comp: Do you currently have any open claims?
If yes, are you now cleared to work?
(If you have an open worker's comp claim but have been cleared to work, you will need to provide a signed doctor's note prior to starting your 1st shift.)
EDUCATION
PROFESSIONAL REFERENCES
Please list three professional references that we may contact:
Employment Application Page 2 of 2
PREVIOUS EMPLOYMENT
If you have a resume, please include it with your application.Optional · PDF, Word, or a photo · 5 MB max
TRAINING / CERTIFICATIONS / TESTING
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. I hereby authorize High Desert ALF to run a CBI background check and a CAPS Check on me prior to being considered for employment.
If this application leads to employment, I understand that false or misleading information in my application and/or interview may result in my immediate release.
I have read and agree to the statements above.
When you submit, we record the date, time, and your internet (IP) address with your signature. Only this application is sent now; the CAPS authorization and the policies are submitted separately with their own buttons.
Submit employment application
2 Written Authorization to Request a CAPS Check Colorado Department of Human Services · CAPS Check Unit · official form wording (Feb 2025 version)
Colorado requires assisted living employers to run a CAPS (Adult Protective Services) check before hiring anyone who will provide direct care. The state requires you to fill in and sign this authorization yourself. Below is the official form's wording with fill-in fields. View the official PDF form (source: CDHS CAPS Check Unit ).
Fill from my application
A check of the Colorado Adult Protective Services (APS) data system (CAPS) is required for you (individual) because you are:
A potential employee/contractor who will provide direct care to at-risk adults, or A person who may be appointed as a conservator or guardian of an at-risk adult. An employer may also request a CAPS check for you if you provide direct care to an at-risk adult and you:
Were hired/contracted prior to the CAPS check requirement (1/1/2019), or Are a volunteer, or Will provide services to a CDASS recipient The CAPS Check will alert the employer or court (agency) whether you have or have not been substantiated in an APS case of mistreating an at-risk adult, to include physical abuse, sexual abuse, caretaker neglect, exploitation, and/or harmful act.
More information on the CAPS check requirement can be found in Colorado Revised Statute (26-3.1-111, C.R.S.) and in the Colorado code of Regulations (12 CCR 2518-01).
Written authorization is required from the individual being checked, using this form. Please complete this form in its entirety. Knowingly providing inaccurate information on a CAPS check request is a class 2 misdemeanor pursuant to 18-1.3-501, C.R.S.
Information obtained through a CAPS Check is confidential and may only be shared with individuals involved in an employer’s hiring process. Third party screening agencies or staffing agencies are authorized to share information received via CAPS Check with employers they are supporting for positions that will provide direct care in accordance with the law.
■ AGENCY INFORMATION (To be completed by the agency.)
Agency Name:
Agency Address:
■ INDIVIDUAL'S INFORMATION (To be completed by the individual being checked.)
First Name:
Middle Name:
Last Name:
Maiden Name/Previous Name(s)/Alias:
Date of Birth:
SSN (Last 4 digits):
DORA License #:(required for all licensed professionals)
Provide the Name(s) of Your Previous Employer(s) Over the Past Five (5) Years:
You must provide at least one (1) personal phone number and one (1) email address. († Cell or Home)
Personal Email Address:
Work Email Address:
Cell Phone:
Home Phone:
Work Phone:
Work Phone Extension:
All individuals are required to provide at least five (5) consecutive years of residential history, regardless of whether in the U.S. or abroad. If you lived outside the US in the past five (5) years, provide the international address(es), including the name of the city and country. If you have lived at your current address less than 5 years, please list your previous addresses for the past 5 years. Use another sheet of paper, if necessary.
Current Address Start Date (DD/MM/YYYY):
Current Street and Number (No PO boxes):
Current Address City:
Current State:
Current Zip/Postal Code:
+ Add a previous address
Authorization
I,
This sends only the signed CAPS Check authorization to the High Desert office, with the date, time, and your IP address.
Submit CAPS authorization
3 Policies & trainings to read and sign The same staff intake policies and house trainings every High Desert employee signs.
Tap a title to open it and scroll through. Check I have read and agree for each one.
Policies
Trainings
By my signature below, I acknowledge that I have received, read, and agree to follow each High Desert Assisted Living policy and training checked above. I understand I may ask the Administrator or General Manager any questions about them, and that they may be updated and I will be asked to re-sign updated versions.
Your contact information
Email Address
Phone
Policy & training acknowledgment signature
This sends your signed acknowledgment of all policies and trainings above, with the date, time, and your IP address.
Submit policy & training sign-off
