CAREGIVER APPLICATION

Are you a caring and dependable caregiver wanting to make a real difference in the lives of seniors and their families by providing compassionate, non-medical in-home care? Are you interested in making a substantially better wage as you deliver this vital service that you’ve been called to do? If you understand and embody a deep awareness of the challenges that arise when individuals and their families are confronted with the aging process, then we would love the opportunity to advance your career by placing you with a client. We are currently recruiting professional caregivers for Part-time, Full-time and Live-in positions nationwide. It only takes a few minutes to complete our online application, so start the process by filling out the fields below.

Contact Information:

Please fill in all the details below, as accurately as possible. We cannot place you with clients that are in your area if we don’t know where you live. We also cannot place you if we can’t reach you.

By checking this box, I affirm my understanding and agreement of the above release

First Name: *

Middle Name:

Last Name: *

Email: *

Phone: *

Alt Phone:

Street Address: *

City: *

State: *

Zip Code: *

Education and Experience:

Please let us know about all of your educational and caregiving experience. Be as accurate as possible. In order to match you with clients, we need to know about your skills, experience, and education. (To select multiple answers, hold down the Control Key [CTRL] while clicking on your answers.)

Educational History

Years of Experience as Caregiver:

Describe Your Experience:

Are you currently employed as a caregiver?

YES

For the following questions, please select all that describe you. (To select multiple answers, hold down the Control Key [CTRL] while clicking on your answers.)

Educational Credentials:

None

LPN/LVN

CNA

Med. Assistant

CCA

PCA

CHHA

Please list your work history for the last 10 years. For each, include your Job Title, Dates Worked, Name of Employer, Name of Supervisor, Reason for Leaving, and Duties Performed:

Please provide 3 Professional References and 3 Personal References. Include their names, how you know them, and the best contact phone number:

Chronic Condition Care Experience: With which conditions do you have care experience?

Arthritis

DiabetesHeart Disease / High Blood Pres.

Alzheimer’s /Dementia

Blindness / Mac. Degeneration

Hearing Loss

Bedridden Clients

Stroke Victims

Catheter Use

Oxygen / Suction

Hospice Care

Developmental Disabilities

Automobile and Driving Information:

Clients who need caregivers to arrive on-time and then assist with transportation and errands expect you to have a reliable, registered, insured car and a clean driving record. Please answer the following questions:

Do you own a reliable, insured car?

Drivers License # and State

Auto Insurance Company:

Auto Insurance Expiration Date:

Availability:

Number of Hours per Week Available to Work:

Shifts Available to Work

Jobs For Which You Are Willing to Interview (Hold down [CTRL] to select multiple):

Respite Care (10 to 30 hrs/wk.)

Full-Time Care (30 to 60 hrs/wk.)

Overnight – Sleeping

Overnight – Awake

Live-in

Alzheimer’s/Dementia

Agencies

Hospice

Facilities

Hourly Wage Desired:

Live-in Wage Desired:

Information to Create the Best Match:

The best assignments are those where your personality, skills, abilities, and interests match the needs and desires of the client. Please be as accurate as possible when answering the following questions because they are used to match you with potential clients in your area.

Other than English, what languages do you speak fluently?

Are you willing to work in the home of smokers?

YES

Are you willing to assist with all pets?

YES

If no, please explain (i.e. hate dogs, allergic to cats, etc.):

Distance Willing to Travel for Job

Background Information:

Our clients expect to interview caregivers with solid references and a clean background. Please let us know a little about your background by answering the following questions:

Do you have proof of your ability to work legally in the United States?

YES

Have you ever been convicted of a felony?

YES

If yes, please explain:

Do you currently have a professional liabilty insurance policy?

YES

Are you willing to take a drug test?

YES

CERTIFICATION AND RELEASE: I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.