Caregiver Application

Are you a caring and dependable caregiver wanting to make a real difference in the lives of seniors and their families?

Are you interested in making a substantially better wage as you deliver this vital service that you’ve been called to do?

Do you have the following qualifications?

- - Two years (or more) of hands-on experience
  - Professional certification (RN, CNA, PCA, LVN, LPN, CCA or equivalent)
  - Legal ability to work (Proof of legal residency, green card, social security card, picture ID, etc.)
  - Clean criminal background check with a seven year look-back
  - Positive professional references that can be verified
  - No state board or other disciplinary actions
  - Clean driving record
  - Current health certificates as applicable (e.g. TB clearance, Hepatitis B screening, etc.)

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 positions nationwide.

It only takes a few minutes to complete our online application, so start the process by filling out the fields below:

Caregiver Application

We would like to set up interviews for you with clients of ours that live in your area. These people are looking for reliable in-home care. In order to be placed, you must fill out the following application (we only accept this online application - please do not try to send us written resumes or applications).

Please Note: All information will be kept in confidence. We do not share or sell data to anyone.

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.

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?

YesNo

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:

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:

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

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?

YesNo

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):

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?

YesNo

Are you willing to assist with all pets?

YesNo

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?

YesNo

Have you ever been convicted of a felony?

YesNo

If yes, please explain:

Do you currently have a professional liabilty insurance policy?

YesNo

Are you willing to take a drug test?

YesNo

Certification and Release:

We're an equal opportunity home care referral agency. All applicants will be considered for caregiving opportunities without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Please read carefully before acknowledging and submitting:

I authorize any of the persons or organizations referenced in the application to give you any and all information concerning my previous employment, education or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and release all such parties from all liability for any damage that may result from furnishing such information to you. I authorize you to request and receive such information.

I understand that my contract is contingent upon verification of past employment; school transcripts; licensures and certifications; satisfactory criminal background check. I hereby consent to such examinations and verifications.

I further understand that I will be required to participate in direct deposit at a bank of your choosing for all payroll transactions.

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers in any application document may disqualify me from further consideration for being a sub-contractor. I further understand that, if contracted, any misrepresentations or omissions of facts in any application document will be cause for my contract to be terminated at any time without prior notice. I understand that my contract may be terminated if I, at any time, reveal confidential information concerning the organization, patients or fellow team members.

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

Enter the above code: