Full Name *

First

Middle

Last

Email *

Phone Number *

Alt Phone Number *

Address *

Address Line 1

Address Line 2

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: *

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.)

Are you currently employed as a caregiver? *

Yes
No

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: *

Chronic 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? *

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?

Yes
No

Are you willing to assist with all pets?

Yes
No

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
No

Have you ever been convicted of a felony?

Yes
No

If yes, please explain: *

Do you currently have a professional liabilty insurance policy?

Yes
No

Are you willing to take a drug test?

Yes
No

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.

Caregiver Application