Availability Form
Applicants Name:
*
First Name
Last Name
Best Contact Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next
Gender:
*
Male
Female
1. Are you willing to work with female patients?
*
Yes
No
2. Are you willing to work with male patients?
*
Yes
No
3.What is your primary Language?
*
English
Spanish
French
Russian
German
4. Click any other languages you speak.
English
Spanish
French
Russian
German
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Next
5. Do you have a car?
*
Yes
No
6. Are you interested in driving clients?
*
Yes
No
6. Are you willing to work with a client who smokes?
*
Yes
No
6. Are you willing to work in a home that has pets?
*
Yes
No
7. Please mark off any pets you allergic to or not willing to work with.
Cats
Dogs
Birds
Other
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8. What areas are you willing to travel, please choose 4 or more locations below:
*
Asheville
Black Mountain
Boone
Brevard
Burnsvillle
Canton
Charlotte
Clyde
Connelly Springs
Flat Rock
Fletcher
Forest City
Gastonia
Hendersonville
Hickory
Huntersville
Kannapolis
Kings Mountain
Laurel Park
Lenoir
Lincolnton
Maggie Valley
Marion
Mars Hill
Marshall
Mills River
Mooresville
Morganton
Mount Holly
Newton
Old Fort
Robbinsville
Rutherfordton
Salisbury
Shelby
Spruce Pine
Stateville
Sylva
Waynesville
Weaverville
Woodfin
Alternative Locations:
Albemarle
Asheboro
Cary
Chapel Hill
Durham
Fayetville
Greensboro
High Point
Matthews
Mebane
Mount Holly
Pinehurst
Raleigh
Rocky Mount
Sanford
Wilmington
Winston-Salem
Please fill in the chart below with the time you are available each day. If you are not available, leave the box blank for that day.
*
Rows
Start (AM/PM)
End (AM/PM)
Sat.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Sun.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Mon.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Tue.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Wed.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Thurs.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Wed.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
Fri.
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
12.00am
1.00am
2.00am
3.00am
4.00am
5.00am
6.00am
7.00am
8.00am
9.00am
10.00am
11.00am
12.00pm
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
I am willing to work Live-in or overnight cases.
*
Rows
Yes
No
Live-In
Overnight
Live-in cases are defined as 24-hour shifts (13hours paid). If choosing "Live-in" please select the following:
*
Please Select
I am willing to work a 7-day live-in.
I am willing to work a 3-4 day live-in.
Not interested.
Please note 7 days live in cases are limited
Signature
*
Date
*
/
Month
/
Day
Year
Date
Submit
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