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.
First Name*
Middle Name
Last Name*
Date of Birth
Address
Address Line 2
City
State
Zip Code
Home Phone
Cell Phone
Soc. Sec. #
Email*
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
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?
Name of High School
Graduate?
Year?
Name of College
If yes, Degree received
Other training
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
Do you have a CNA License?YESNO
Do you have a CPR Certification?YESNO
Do you have a FIRST AID Certification?YESNO
Have you had COVID-19 Vaccine(s)?YESNO
Do you have a State ID Card?YESNO
Do you have a Passport or Birth Certificate?YESNO
Please provide your most recent positions of employment.
Employer
Supervisor
Phone Number
Address 1
Address 2
Zip
Please provide professional references.
Name
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.
Upload Resume
I hereby certify that the information herein is correct to the best of my knowledge, and I understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal. By Signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.
I, hereby authorize Excellent Home Caregivers, Inc. to investigate my background and qualifications for purposes of evaluating whether I am qualified for the position for which I am applying. Read More
