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Submit a Caregiver Application
Thank you for your interest in working as a caregiver for our company. Please complete the application below and hit the submit button. We will be in touch with you shortly after we receive your completed application.

PLEASE COMPLETE ALL QUESTIONS

NOTE: For This Type of Employment Senior Helpers Requires a Criminal Background Check as Condition of Employment. Applicants may be tested for illegal drugs.

* = Required

Personal Information
 
  Please indicate the days and times you are available to work:
Work anytime?
Applied here before?
*Are you available
to work nights?
*Are you available
to work weekends?

Education Information
TYPE OF SCHOOL NAME OF SCHOOL CITY STATE/PROVINCE YEARS COMPLETED DEGREE MAJOR
High School
College
Bus. or Trade School
Professional School

*Have you ever been convicted of a crime?
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment):

*Have you ever worked under a different name?
If YES, what was it and what was the reason?

*Do you have any relatives or friends that work for the Company?
If YES, what is their name?

In Case of Emergency, Please Contact:

*Name
 *Relation
*Phone
 Business Phone

Driving Information

*Do you have a driver's license?
*Do you have auto insurance?
*Do you have a car?
--
*Have you had any accidents
during the past 3 years?
How many?
*Have you had any moving violations
during the past 3 years?
How many?

Personal Reference Information

List two personal references. DO NOT LIST relatives or previous supervisors.
*An application form sometimes makes it difficult to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications to be a caregiver. Please note any experience with caregiving professionally, for your parents, spouse, children or friends.
*Why do you enjoy caregiving?
*Please describe some of your volunteer work:

Please list any certifications you currently possess:

Certified Nursing Assistant Certified Medical Technician
Certified Medicine Aide CPR Certified
Geriatric Nursing Assistant First Aid Certification
Certified Home Health Aide Personal Support Worker

Work Experience

Please list at least two of your work experiences for the past five years beginning with your most recent job held. If you were self-employed, give company name.
Current or Most Recent Employer Information
  Employment Dates   Pay or Salary
From
--
*Start
To
--
*Final
*Reason for leaving (be specific):
*List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
*May we contact your present employer?
If NO, Please Explain Why and Please Provide Us With Another Work Reference:


Additional Employer Information
  Employment Dates   Pay or Salary
From
--
*Start
To
--
*Final
*Reason for leaving (be specific):
*List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
*May we contact this employer?
If NO, Please Explain Why and Please Provide Us With Another Work Reference:


Skill Information

How would you rate yourself on your experience with the following aspects of caregiving?
    1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience

Companionship
Dressing/Grooming
Meal Preparation
Transferring
Light Housekeeping
Incontinence Care
Bathing/Showering
Dementia/Alzheimer's Care