Apply Now

Apply Now

    Thank you for your interest in working for our home care agency.
    Please submit the application below to be considered for a position as a caregiver.


    APPLICANT INFORMATION

    First Name*
    Middle Name
    Last Name*
    Date of Birth
    Address
    Address Line 2
    City
    State
    Zip Code
    Home Phone
    Cell Phone
    Soc. Sec. #
    Email*



    TYPE OF POSITION DESIRED

    Hourly/Come & Go (Part-Time)Hourly/Come & Go (Full-Time)LIVE-IN 24/7 (Full-Time)
    Please note that some of our clients prefer caregivers who can drive. However, we also have some clients that do not need a live-in who drives.
    PLEASE INDICATE DAYS AND HOURS OF AVAILABILITY TO WORK BELOW.
    Sunday
    Monday
    Tuesday
    Wednesday
    Thursday
    Friday
    Saturday



    MATCH CRITERIA

    Please answer the following questions either yes or no.
    Do you have Alzheimer’s or Dementia Experience with past client(s)?YESNO
    Do you have Parkinson’s Experience with past client(s)?YESNO
    Do you have Hospice Experience with past client(s)?YESNO
    Do you have Bathing/Shower experience with past client(s)?YESNO
    Do you have Meal Prep/Cooking experience with past client(s)?YESNO
    Do you have Feeding Tube Experience with past client(s)?YESNO
    Do you have Incontinence Care Experience with past client(s)?YESNO
    Do you have Catheter Care Experience with past client(s)?YESNO
    Do you have Colostomy Care Experience with past client(s)?YESNO
    Do you have Gait Belt Experience with past client(s)?YESNO
    Do you have Hoyer Lift Experience with past client(s)?YESNO
    Do you have Slide Board Transfer Experience with past client(s)?YESNO
    Are you ok with Client Smoking?YESNO
    Are you OK with Cats?YESNO
    Are you OK with Dogs?YESNO
    Other Skills?



    EDUCATION & TRAINING

    Name of High School
    Graduate?
    Year?
    Name of College
    Graduate?
    Year?
    If yes, Degree received
    Other training



    CERTIFICATIONS & CREDENTIALS

    Please answer “yes” or “no” for each question. If you answer yes to a question, please provide date certified or expiration date. Thank you.


    Do you have a Driver’s License?YESNO
    Date or Dates

    Do you have Car Insurance?YESNO
    Date or Dates

    Do you have a CNA License?YESNO
    Date or Dates

    Do you have a CPR Certification?YESNO
    Date or Dates

    Do you have a FIRST AID Certification?YESNO
    Date or Dates

    Have you had COVID-19 Vaccine(s)?YESNO
    Date or Dates

    Do you have a State ID Card?YESNO
    Date or Dates

    Do you have a Passport or Birth Certificate?YESNO
    Date or Dates



    EMPLOYMENT HISTORY

    Please provide your most recent positions of employment.

    EMPLOYER #1 (your most current employer)

    Employer
    Supervisor
    Phone Number
    Address 1
    Address 2
    City
    State
    Zip

    EMPLOYER #2

    Employer
    Supervisor
    Phone Number
    Address 1
    Address 2
    City
    State
    Zip

    EMPLOYER #3

    Employer
    Supervisor
    Phone Number
    Address 1
    Address 2
    City
    State
    Zip



    PROFESSIONAL REFERENCES

    Please provide professional references.

    Name
    Phone Number
    Name
    Phone Number
    Name
    Phone Number



    ADDITIONAL INFORMATION

    Have you ever been convicted of a crime other than a minor traffic violation?YESNO
    If yes, please explain and give date of conviction.
    Are you legally eligible to work in the United States?
    Please provide emergency contact name(s), telephone, and relationship to you.


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    DISCLAIMER



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