CONFIDENTIAL

LIVE-IN HOUSE ASSISTANT

Red = Required Field  

Miss, Ms, Mrs. Mr.

Ms Miss Mrs. Mr.

First /Given Name(s) :

Surname /Family Name :

Street :

City :

Telephone - including full local or international code (daytime)

Email :

Date of Birth (dd/mm/yy) 

All applicants other than Canadian Citizens, Landed Immigrants and Permanent Residents of Canada require a work permit to be employed by L’Arche.

What is the expiration date on your passport?   2007 2008 2009 2010 2011 2012

Are you legally eligible to work in Canada?  YES    NO

Do you anticipate any difficulties in obtaining a work permit?  YES    NO

If yes, please elaborate 

Have you ever been employed by, volunteered in, or visited  a L'Arche community before?    YES    NO   

B  RELEVANT INFORMATION

How did you hear about L'Arche?

Why do you wish to come to a L’Arche community?

How long would you hope to be in L’Arche?

(We give priority to those who can commit for at least one year)

What are your goals for yourself in coming to L’Arche? 

Have you read the Charter of L'Arche? (You can read  this document now by clicking on the link here, you can return to this form by clicking on the "Back" button at the top of your browser.)

When would you be available to start?  January February March April May June July August September October November December 2007 2008

Highest Level of Education completed:

Description High School Partial Undergraduate College Diploma Other Diploma or Cert. Undergraduate Degree Masters Degree Doctorate

 Field of Study:

Please describe any additional education, work, volunteer or life experience that would be relevant to your application as a live-in house assistant:

Do you have a valid driver’s licence? 

YES    NO

Number of years of insured driving experience

0-5 6-10 11-15 16-20 More than 20

How would you describe your ability to speak English?

Description Excellent Above Average Average Fair None

How would you describe your ability to speak French? 

Description Excellent Above Average Average Fair None

Since you will be providing personal care for individuals who are vulnerable, we ask that you please complete the following health questions. If your application is accepted you will be required to obtain a medical review before you arrive.

If the answer is yes to any of the above, please elaborate. 

Do you have any communicable diseases?

YES    NO

If so, please describe: 

Title, Initial(s) & Family name  

Address    

Postal Code 

Email:

Telephone No. (Daytime)    (Evening)  

How many years has this person known you? 3 4 5 more than 5

In what capacity? 

Title, Initial(s) & Family name  

Address    

Postal Code 

Email:

Telephone No. (Daytime)    (Evening)  

How many years has this person known you? 1 2 3 4 5 more than 5

In what capacity? 

Title, Initial(s) & Family name  

Address    

Postal Code 

Email:

Telephone No. (Daytime)    (Evening)  

How many years has this person known you? 1 2 3 4 5 more than 5

In what capacity? 

Is there anything else you would like us to know with regard to your application?

If you wish this application to be forwarded ONLY to specific communities please list them in the following box

IMPORTANT NOTE: Please apply only one time. Your application will only be processed in one community at a time and not concurrently. If you are applying on line you do not need to contact individual communities.

I declare that the information given on this form is to the best of my knowledge true and complete. I agree to L’Arche taking up any references in connection with this application and understand that these will be confidential between the referee and L’Arche. I also agree to any Criminal Records Bureau or Police checks which may be required as part of L’Arche’s recruitment procedures.

I agree that the information provided in this application form may be processed by L’Arche in relation to my application for this position to assist in the decision making process. I further expressly agree that, should it be necessary to validate any of the information provided therein, L’Arche may release the information for verification purposes. If I am successful in my application, it is agreed that any information provided will be retained by L’Arche in a secure and confidential file, and the contents only used for necessary business purposes, subject to my express consent for disclosure where necessary.

Feb. 11, 07