Interested in becoming a member of our team? Please complete and submit the form below:



Criminal Background

  • About You
  • Education
  • Criminal Background
  • Military and Work Experience
  • Application For Waiver

About You

Are you over 18 years of age?

Days / Hours available to work

Can you work nights?

Employment desired


Driver's License


Have you been convicted of a DUII in the past 5 years?

Have you had any moving violations (including accidents) during the past three years?


Have you ever been convicted of a felony?

Have you ever been convicted as a sex offender?




Work Experience

Please list your work experience for the past five years beginning with your most recent job held. Experience If you were self-employed, give firm name. Attach additional sheets if necessary.

Application For Waiver

In exchange for the consideration of my job application by Brookside Memory Care (hereinafter called “the Company”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Brookside Memory Care, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President/Executive Director of the Company. Both the undersigned and Brookside Memory Care may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the company from any liability as a result of such contract.

I also understand (1) the Company has a drug and alcohol policy that may provide for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy.

I further understand that continued employment may be based on the successful passing of job-related physical examinations. I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Disclosure and Consent

In connection with the hiring process of Brookside Memory Care and Palliative Care, I understand that the Company may utilize the services of a background screening service agency. The information research will be in accordance to the job description and the Brookside Memory Care and Palliative Care pre-employment background checklist. This information will be used in the hiring process to determine a continued offering of employment with Brookside Memory Care and Palliative Care.

I understand that this information may include, but is not limited to, the preemployment background checklist. I understand that before Brookside Memory Care and Palliative Care take any adverse action based in whole or in part on information contained in the report, I will be provided a description in writing of my rights under the Fair Credit Reporting Act. If any adverse action is to be taken, an applicant will have the opportunity to meet with the Human Resource Department and explain any discrepancies.

I hereby consent to this pre-employment background check and authorize the Company to procure a report as stated above from a background screening agency. This authorization shall remain on file and shall serve as ongoing authorization for Brookside Memory Care and Palliative Care to procure such reports at any time during my employment with the Company.

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