Caregiver Referal Registration Form
Thank you for applying to Senior Pros. This application must be completed in its entirety. Allow 15-45 minutes to complete this form.
Position Applying For:
HHA - Home Health Aide
CNA - Certified Nursing Assistant
LPN - Licensed Practical Nurse
RN - Registered Nurse
Office/Administration
Sales/Marketing
Number of years of experience in in-home healthcare
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
Cell Phone/Text Number
Please enter a valid cell phone number.
Home/Alternate Phone Number
Please enter a valid phone number.
Brithdate
-
Month
-
Day
Year
Date
Social Security Number
COVID Vaccine Satus:
Vaccine and all boosters (have card)
Vaccine only (have card)
No Vaccine card
Other
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Availability and Transportation
Available Days: Please check the days you are typically available to work. Senior Pros requires all Caregivers are available for work at least two weekends per month. Caregivers that are avaialbe weekends are prioritized.
Monday
Tuesday
Wednesday
Thursday
Friday
Every Saturday
Every Sunday
Every other Saturday
Every other Sunday
How many days/hours would you like to work per week?
Expected Hourly/Shift Pay
If there are any days you are NEVER able to work (i.e. another job, school, etc.) please list the days and reason here:
What times are you typically available to work? (Check all that apply)
Mornings
Afternoons
Evenings
Nights
Overnights
Live-in
Live-in only
How many hours per shift? (Check all that apply)
4 Hours
6-8 Hours
8-12 Hours
12+ Hours
Live-in
Other
Tranpsortation
Which best describes your mode of transportation? (Check all that apply)
I will drive to the client and can use my car to transport the client. (Mileage reimbursement provided.)
I will drive my car to the client, but not drive the client in my car.
I drive, but do not have a car to use for work
I drive and will drive the client in their car.
I do not drive.
I depend on public transportation, rideshares (Uber) or others to get to the client.
I only want live-in assignments where driving/car is not required.
Other
Your car: YEAR
blanks
MAKE/MODEL
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Work Experience, Education References
Previous Employer 1
Previous Employer 2
High School
College
School You Received Your Home Healthcare Training Certificate or License
Personal Reference 1
Personal Reference 2
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Skills and Client Preferences
This section will allow us to refer you to clients who are the best match for your skills and preferences.
Do you prefer to work with male or female clients:
Males
Females
No Preference
Will you work with a client located at: (Check all that apply)
In their home
In a facility
I will NOT work in a home with a spouse or other person in the home.
I will work with a couple.
Other
Skills and Work Responsibilities (Check all that apply)
Will Work with Alzheimer/Dementia
Will work with Incontinence/Diapers
Will transfer a client (from bed to wheelchair, wheelchair to toilet, etc.)
Will work with a bedridden client
Able to use a manual Hoyer Lift (one person)
Basic cooking
Advanced cooking
Light/Moderate Housekeeping
Help to use computer/internet/email/facetime, etc.
Help with Physical Therapy, exercises, etc.
Provide companionship (conversation, play games, memory skills, cooking together, etc.)
Prefer to run errands, take the client to appointments, shop, have social engagements, etc.
Prefer to work with a client who is more homebound, and/or sedintary.
Experience working in a Kosher Home
Will work with COVID Client
Other
Pets/Pet Care (Check all that apply)
Okay if Client has a cat
Okay if Client has a small dog
Okay if Client has a large dog
Will assist with pet care
Will NOT assist with pet care
Will NOT work in a home with pets.
Pet allergies
Other
List any foreign languages you speak:
Do you have any physical conditions or limitations we should consider when matching you with a client? (i.e back issues that prevent you from performing transfers, etc.)
Please use this space to add any comments or list other skills or experience you will bring to the client:
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Document Uploads
It is not required that you upload your documents with this application. You can bring them with you to your interview and orientation. The documents listed here are required for your file and before we can place you on an assignment. All files must be clear, in focus, cropped, and all four corners of the document must show.
Drivers License (Front Side Only)
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Social Security Card
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CNA, LPN, RN License
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of
Covid Vaccine Card
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of
CPR Card/Certificate
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HHA Certificate (Front)
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of
HHA Certificate (Back with curriculum)
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Physician's Health Statement: Must be issued less than 6 months ago and must include "(your name) is free from communicable diseases)
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HIV/AIDS Inservice Certificate
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Assistance with the Self Administration of Medicine Certificate
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Choose a file
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Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature
Printed:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: