Caregiver Job Application

1
Name* This field is required.Legal first and last name.
First Name
Middle Name
Last Name
2
Phone Number* This field is required.Please provide the best contact information for your review.
3
E-mail* This field is required.Official contact email information,
example@example.com
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4
Which shift for "Personal Care Assistant (PCA)":Please provide shif or time seeking for placement.
5
Total number of years experience as a Caregiver?:* This field is required.This mean as a volunteer or other wise.
6
Address* This field is required.Your Official mailing address,
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Date of Birth* This field is required.Your legal date of birth.
Date
Month
Day
Year
8
SSNPlease provide your SSN
9
Proof of ID- State issued official document.* This field is required.No expired documentations allowed.
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10
I meet the following requirements (check all that apply):* This field is required.Please tell us the following, you can pick as many as you would like.
Passion for caring for others & education
Professional Outlook
Knowledgeable about ages & stages
Stellar references
Pristine background
Reliable & prompt
Able to commit to job timeline
21+ years old
Clear driving record
Safe & ensured vehicle
Non-smoker
Can legally work in the U.S.
Current CPR/FA certification or willingness to renew
11
Resume PleaseMost recent resume on hand.
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12
Are you 21 years of age or older?
Yes
No
13
Are you authorized to work In The United States?
Yes
No
14
Are you currently living in the United States?
Yes
No
15
Where are you located?
Please list the neighborhood you reside in.
16
Do You Own A Car?
Yes
No
17
Do You Have A Drivers License?
Yes
No
18
Areas you are comfortable commuting to:
19
Distance Willing To Travel?
Please Select
Please Select
Over 30 Mile Radius
Below 30 Mile Radius
Public Transit Only
20
Date You Can Start
Date
Month
Day
Year
21
Salary Desired
22
Position Interested In (check all that apply):
Full Time
Part Time
Temporary
On Call
23
Experienced With:
Multiples
Special Needs
Allergies
24
Introduce yourself to a prospective client by sharing a personal letter about your experience. Include qualities that make you an outstanding nanny and why you've chosen this profession:
Important Note: This is much more than a job to us. We are looking for caregivers that understand the significance of being welcomed into a family to nurture their children. Additionally, we highly value professional letters written with attention to detail (grammar, punctuation, etc.).
25
List three words that describe your personality:
26
What skills and experience do you have that are useful for nannying? Feel free to be as in depth as possible.
27
CPR/First Aid Certified?
Please Select
Please Select
Yes
No
Willing to Get Certified
28
CPR/First Aid Expiration Date
Month
Day
Year
29
Name of CPR/FA instructor:
30
Phone number for CPR/FA instructor:
31
Can You Swim?
Please Select
Please Select
Yes
No
32
List any additional health & safety trainings you may have had or have:
33
Anything else you would like to share:
34
Include links to your social media profiles, so we can get to know you better:
35
OPTIONAL: Upload a recent photo of yourself (5MB or smaller gif, png, jpg, or jpeg file)
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36
Highest Level of Education:
Please Select
Please Select
High School
College
Graduate School
37
High School
Name of High School Attended
38
Graduated High School?Yes No
Please Select
Please Select
Yes
No
39
College
Name of College/University Attended
40
Graduated College?
Please Select
Please Select
Yes
No
41
Number of Years Attended College
42
College Area of Study/Degree
43
44
Graduate School
Name of Graduate School Attended
45
Graduated Grad School?
Please Select
Please Select
Yes
No
46
Number of Years Attended
47
Area of Study/Degree
48
49
Trade School/Other
Name of Trade/Technical/Other School Attended
50
Graduated From Trade School?
Please Select
Please Select
Yes
No
51
Number of Years Attended
52
Area of Study/Degree
53
List of other professional training:
i.e. STARS, NCS, Doula training, conference workshops, etc.
54
Current Employer Name
i.e. Name of Family
55
Current Employer Position
Your job title
56
Current Employer Salary
57
Current Employer Start Date
Date
Month
Day
Year
58
Current Employer Location
i.e. Neighborhood
59
Current Employer Children's Ages
60
Current Employer Duties
Please include an in-depth job description
61
Current Employer May We Contact?
Yes
No
62
Please explain why we may not contact your current employer:
63
64
Previous Employment
65
Previous Employer
i.e. Name of Family
66
Previous Employer Position
Your job title
67
Previous Employer Salary
68
Previous Employer Start Date
Date
Month
Day
Year
69
Previous Employer End Date
Date
Month
Day
Year
70
Previous Employer Location
i.e. Neighborhood
71
Previous Employer Children's Ages
72
Previous Employer Duties
Please include an in-depth job description
73
Previous Employer Reason for Leaving?
74
Previous Employer May We Contact?
Yes
No
75
Please explain why we may not contact your previous employer:
76
77
Third Recent Employer
i.e. Name of Family
78
Third Recent Employer Position
Your job title
79
Third Recent Employer Salary
80
Third Recent Employer Start Date
Date
Month
Day
Year
81
Third Recent Employer End Date
Date
Month
Day
Year
82
Third Recent Employer Location
i.e. Neighborhood
83
Third Recent Employer Children's Ages
84
Third Recent Employer Employer Duties
Please include an in-depth job description
85
Third Recent Employer Reason for Leaving?
86
Third Recent Employer May We Contact?
Yes
No
87
Please explain why we may not contact your third recent employer:
88
Fourth Recent Employer
i.e. Name of Family
89
Fourth Recent Employer Position
Your job title
90
Fourth Recent Employer Start Date
Date
Month
Day
Year
91
Fourth Recent Employer End Date
Date
Month
Day
Year
92
Fourth Recent Employer Location
i.e. Neighborhood
93
Fourth Recent Employer Children's Ages
94
Fourth Recent Employer Employer Duties
Please include an in-depth job description
95
Fourth Recent Employer Reason for Leaving?
96
Fourth Recent Employer May We Contact?
Yes
No
97
Please explain why we may not contact your fourth recent employer:
98
Fifth Recent Employer
i.e. Name of Family
99
Fifth Recent Employer Position
Your job title
100
Fifth Recent Employer Start Date
Date
Month
Day
Year
101
Fifth Recent Employer End Date
Date
Month
Day
Year
102
Fifth Recent Employer Location
i.e. Neighborhood
103
Fifth Recent Employer Children's Ages
104
Fifth Recent Employer Employer Duties
Please include an in-depth job description
105
Fifth Recent Employer Reason for Leaving?
106
Fifth Recent Employer May We Contact?
Yes
No
107
Please explain why we may not contact your fifth recent employer:
108
Sixth Recent Employer
i.e. Name of Family
109
Sixth Recent Employer Position
Your job title
110
Sixth Recent Employer Start Date
Date
Month
Day
Year
111
Sixth Recent Employer End Date
Date
Month
Day
Year
112
Sixth Recent Employer Location
i.e. Neighborhood
113
Sixth Recent Employer Children's Ages
114
Sixth Recent Employer Employer Duties
Please include an in-depth job description
115
Sixth Recent Employer Reason for Leaving?
116
Sixth Recent Employer May We Contact?
Yes
No
117
Please explain why we may not contact your sixth recent employer:
118
May we contact your references?
Yes
No
119
Reference One
Name of Reference
120
Reference One Relationship
121
Reference One Years Acquainted
122
Reference One Phone
123
Reference One Email
example@example.com
124
125
Reference Two
Name of Reference
126
Reference Two Relationship
127
Reference Two Years Acquainted
128
Reference Two Phone
129
Reference Two Email
example@example.com
130
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Reference Three
Name of Reference
132
Reference Three Relationship
133
Reference Three Years Acquainted
134
Reference Three Phone
135
Reference Three Email
example@example.com
136
137
Reference Four
Name of Reference
138
Reference Four Relationship
139
Reference Four Years Acquainted
140
Reference Four Phone
141
Reference Four Email
example@example.com
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Reference Five
Name of Reference
144
Reference Five Relationship
145
Reference Five Years Acquainted
146
Reference Five Phone
147
Reference Five Email
example@example.com
148
Please Upload Your Cover Letter
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Max. file size: 10.0MB
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149
Please Upload Your Resume
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Max. file size: 10.0MB
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150
AcknowledgementCaregiver Duties Disclosure Statement As part of the application process for the position of caregiver, the following duties, responsibilities, and reporting requirements must be fully understood and agreed to by the applicant: Duties and Responsibilities Provide compassionate, respectful, and professional care to the assigned individual(s), including but not limited to assistance with activities of daily living, medication management, transportation, meal preparation, housekeeping, and emotional support. Maintain accurate and timely documentation of all care provided, including medication administration, incidents, and changes in the client’s condition. Communicate promptly and clearly with family members, healthcare professionals, and supervisors regarding any concerns or emergencies. Uphold all state, local, and agency-specific regulations and ethical standards related to caregiving. Reporting Requirements Complete all required reports and documentation as specified by the agency and applicable laws. Submit all reports within designated timeframes. Cooperate fully with audits, evaluations, and investigations related to caregiver duties. Compliance and Penalties I understand and acknowledge that failure to comply with all reporting requirements may result in immediate removal from caregiving duties, termination of employment, and/or criminal or civil charges being filed against me. I further acknowledge that non-compliance may trigger a fine of up to $500,000.00, depending on the severity and nature of the violation, as determined by the relevant authorities. By signing below, I affirm that I have read, understand, and agree to abide by the caregiver duties and reporting requirements stated above.
I have uploaded my resume. Without a resume, I understand that my application may not be considered.
Should be Empty: