Caregiver Application
Legal Name
First Name
Middle Name
Last Name
Preferred Name
Preferred Pronouns
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Total number of years experience in caregiving (experience preferred but not required)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Are you authorized to work In The United States?
Yes
No
Do you have CA drivers license?
Yes
No
Skills/Qualifications:
Please select the shift types that you are available for
*
Mon-Fri 9am-3pm
Mon-Fri 3pm - 8pm
Mon-Fri 3pm - 9am (with sleeping overnight until 9am the following day)
Mon-Fri 8pm - 9am (with sleeping overnight until 9am the following day)
Sat-Sun 9am-3pm
Sat-Sun 3pm - 8pm
Sat-Sun 3pm - 9am (with sleeping overnight until 9am the following day)
Sat-Sun 8pm - 9am (with sleeping overnight until 9am the following day)
List three words that describe your personality:
What skills and experience do you have that are useful for caregiving? Feel free to be as in depth as possible.
CPR/First Aid Certified?
Please Select
Yes
No
Willing to Get Certified
*not required - Will be provided if hired
CPR/First Aid Expiration Date
-
Month
-
Day
Year
Education
Highest Level of Education:
Please Select
High School
College
High School
Name of High School Attended
Graduated High School?
Please Select
Yes
No
College
Name of College/University Attended
Graduated College?
Please Select
Yes
No
Number of Years Attended College
College Area of Study/Degree
Job History
Current Employer Name
i.e. Name of Family
Current Employer Position
Your job title
Current Employer Start Date
-
Month
-
Day
Year
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Current Employer Duties
Please include an in-depth job description
Why do you find yourself looking for new or additional work?
*
Previous Employer
Previous Employer Position
Your job title
Previous Employer Start Date
-
Month
-
Day
Year
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Previous Employer End Date
-
Month
-
Day
Year
Date Picker Icon
Previous Employer Duties
Please include an in-depth job description
Previous Employer Reason for Leaving?
Do we have your permission to contact previous employers?
Yes
No
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References
Reference One
*
Name of Reference
Reference One Relationship
Reference One Email
example@example.com
Reference One Phone
Reference Two
Name of Reference
Reference Two Relationship
Reference Two Phone
Reference Two Email
example@example.com
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