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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