Caregiver/Clinical OFFSITE Registration

Caregiver/Clinical Registration

Please complete the form below to register as an Independent Contractor with us.
BEFORE YOU START: Please be aware that we require all documents to be uploaded here in the registration. If you do not have digital copies of your documents, you may take CLEAR photos of the original documents and upload the photos. ***ALL fields of the document must be clear or your registration may not be processed.
FULL NAME - As per the Internal Revenue Federal Regulations, you must print your name exactly as it is shown on your SS card. Per the Internal Revenue Service Regulations, all payments/pay checks will be issued by CareGivers of America in the name that appears on your Social Security Card. *

First Name Middle Name Last Name(s)
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Social Security Number - As per the Internal Revenue Federal Regulations, you must print your Social Security number exactly as it is shown on your SS card. Per the Internal Revenue Service Regulations, all payments/pay checks will be issued by CareGivers of America in the name and SS that appear on your Social Security Card. *
What is your date of birth? DD/MM/YEAR format: *
Email Address *
example@example.com
Phone Number *

Area Code Phone Number
How were you referred to us? *

Walk In Friend/Family Indeed CareerBuilder Simply Hired Facebook Job Fair Other MyCNAJobs
Which Certification/License applies to you? Choose all that apply: *

Home Health Aide CNA RN LPN Other
If you are a HHA, please list the YEAR you were certified. ***If you are a CNA, LPN or RN, please list the year your license EXPIRES. *
***If you are a CNA, LPN or RN, please list your License #
Registering for Position *
Desired start date

Month Day Year
Date
DOCUMENT UPLOAD: Color uploads required (NOT photo copies). You may upload a CLEAR photo of the document with your phone; ALL areas / fields of document MUST be clear. Pursuant to Florida state law, we cannot process a registration without the below documents.
Upload Resume

Upload a File

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Upload Social Security Card (must be original) FRONT. *

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Upload Social Security Card (must be original) BACK. *

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Upload Home Health Aide Certificate FRONT

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Home Health Aide Certification BACK

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Upload CNA, LPN, or RN License (if you have one)

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Upload Domestic Violence In-Service Certificate *

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Upload OSHA In-Service Certificate *

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Upload HIV/AIDS In-Service Certificate *

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Upload Alzheimer's and Related Disorders In-Service Certificate *

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Upload Assisting With Self Medication In-Service Certificate *

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Upload a copy of your Physical (cannot be older than 6 months and it must state "Free from communicable disease" or "No apparent signs/symptoms of communicable disease") *

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Upload TB Test or Chest X-Ray *

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Upload valid CPR Certificate/Card FRONT *

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Upload valid CPR Certificate/Card BACK *

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Upload valid Driver's License / OR a valid Florida ID if you do not drive *

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Upload Voter's Registration, Passport or Birth Certificate (if U.S. Citizen). ***If you are not a U.S. Citizen, upload your original valid Resident Alien Card or Employment Authorization

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Upload Liability Insurance (If you do not have it, we can assist you in obtaining it).

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Upload Green Card FRONT here (if applicable):

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Upload Green Card BACK here (if applicable):

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Upload Fraud, Waste and Abuse In-Service Certificate here:

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Upload Abuse, Neglect and Exploitation In-Service Certificate here:

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Upload Cultural Diversities In-Service Certificate here:

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Upload Covid vaccination document here:

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Upload most recent Covid test document here:

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Upload additional In-Service Certificate here:

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Upload additional In-Service Certificate here:

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Upload additional In-Service Certificate here:

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WORK HISTORY:

Please list below 3 previous employers:
Work History #1
Full Name of Agency, Facility or Employer *
Address of Agency, Facility or Employer: *
Phone Number *

Area Code Phone Number
Date Employment Started *

Month Day Year
Date
Date Employment Ended

Month Day Year
Date
Work History #2
Full Name of Agency, Facility or Employer *
Address of Agency, Facility or Employer: *
Phone Number *

Area Code Phone Number
Date Employment Started *

Month Day Year
Date
Date Employment Ended

Month Day Year
Date
Work History #3
Full Name of Agency, Facility or Employer *
Address of Agency, Facility or Employer: *
Phone Number *

Area Code Phone Number
Date Employment Started *

Month Day Year
Date
Date Employment Ended

Month Day Year
Date
EDUCATIONAL HISTORY:
Educational History #1
Full Name of School: *
Address of School: *
Year Completed: *
Diploma, Certification, or License received: *
Educational History #2
Full Name of School: *
Address of School: *
Year Completed: *
Diploma, Certification, or License received: *
EMERGENCY CONTACT:

Please list your emergency contact person's information:
Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone number *
Alternate phone number
Relationship *
Caregiver Availability

Please fill in the following sections:
Are you a driver? *

Yes No
Do you own a car? *

Yes No
What kind of car do you drive? (2-door, 4-door, SUV, make and model, etc.)
WORK AVAILABILITY
Areas In Which You Are Available

Please click on all that apply:
PALM BEACH COUNTY *

Jupiter Palm Beach Gardens Royal Palm Beach West Palm Beach Lake Worth Boynton Beach Delray Beach Boca Raton Not available for work in Palm Beach County
BROWARD COUNTY *

Deerfield Beach Pompano Beach Fort Lauderdale Plantation Davie Weston Hollywood Miramar Hallandale Beach Not available for work in Broward County
MIAMI-DADE COUNTY *

Aventura Miami Kendall Not available for work in Miami-Dade County
Schedule Availability

Please click on all that apply:
Are you available for hourly work? *

Yes No Maybe
Are you available for live-in work? *

Yes No Maybe
Live-In Aide Responsibility:

A Live-In Aide is entitled to a minimum of 8 hours of uninterrupted sleep per night. It is your responsibility to advise CareGivers of America to report sleep time interruptions.
How many hours per week are you willing to work: *

Less than 25 hours 25 - 40 hours
What days are you available to work? Check all that apply: *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What shifts can you work? Check all that apply: *

Mornings Afternoons Evenings Late night or overnight
Are you comfortable with: (check for yes) *

Lifting Hoyer lift Pets People in home who smoke None of the above
FDLE: Please be advised that CareGivers of America runs a background screening through the Florida Department of Law Enforcement.
SIGNATURE: By e-signing below, you are solemnly swearing that you have never been arrested or convicted of any offense.
Signature *

Clear
Please note the following important information below:
Authorization and Consent: I grant authorization and consent to CareGivers of America to conduct a criminal background check, conviction records check, abuse registry check, previous employment reference check and driving record check for the purpose of my Independent Contractor Agreement with CareGivers of America and its affiliated corporations/agencies.
Release of Liability regarding background checks: I authorize the disclosure of employment information and I release CareGivers of America and the provider of such information from any and all liability for damages arising from the investigation and disclosure of the requested information. I allow a photocopy/fax/email copy of this authorization to be as valid as the original.
*Signature: I have read the above sections of Authorization and Consent and Release of Liability and sign below that I understand and authorize:
Signature *

Clear
Completion of Registration: I certify by signing below that the information provided here is accurate and true.
Signature *

Clear
CareGivers of America

4450 N University Dr, Lauderhill, FL 33319

Broward: 954-722-7662 Miami-Dade: 305-654-7414 Palm Beach: 561-832-0504
Should be Empty:

Caregiver/Clinical Registration

DOCUMENT UPLOAD: Color uploads required (NOT photo copies). You may upload a CLEAR photo of the document with your phone; ALL areas / fields of document MUST be clear. Pursuant to Florida state law, we cannot process a registration without the below documents.

WORK HISTORY:

Work History #1

Work History #2

Work History #3

EDUCATIONAL HISTORY:

Educational History #1

Educational History #2

EMERGENCY CONTACT:

Caregiver Availability

WORK AVAILABILITY

Areas In Which You Are Available

Schedule Availability

Live-In Aide Responsibility:

FDLE: Please be advised that CareGivers of America runs a background screening through the Florida Department of Law Enforcement.

SIGNATURE: By e-signing below, you are solemnly swearing that you have never been arrested or convicted of any offense.

Please note the following important information below:

*Signature: I have read the above sections of Authorization and Consent and Release of Liability and sign below that I understand and authorize:

Completion of Registration: I certify by signing below that the information provided here is accurate and true.