Caregiver Application
Name/Nombre
*
First Name
Middle Name
Last Name
Phone Number/Telefono
*
Format: (000) 000-0000.
E-mail/Correo Electronics
*
example@example.com
Date of Birth/Fecha de Nacimiento
*
-
Month
-
Day
Year
Date
Social Security #/Seguro Social
*
**for background check**
Total number of years experience in caregiving/AÑos de experiencia
*
Address/Direccion
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select checkboxes that match your skills and preferences.
Alzheimer's/Dementia Experience
OK with cats
Live-In Shifts OK
OK with dogs
Ok with Client Smoking
Reliable & prompt
Able to commit to job timeline
18+ years old
Willing to drive clients
Safe & ensured vehicle
Can legally work in the U.S.
Ok with lifting client from bed/toilet
Available to work nights
Distance Willing To Travel/Distancia dispuesta a viajar
*
Please Select
Over 30 Mile Radius
Below 30 Mile Radius
Public Transit Only
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Employment Desired:
Date You Can Start/Fecha en la qua puede empezar
*
-
Month
-
Day
Year
Date Picker Icon
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Additional Information:
What do you like most about working with the elderly, disabled, or convalescing?/ ¿Qué es lo que más le gusta de trabajar con personas mayores, personas con discapacidad o personas en convalecencia?
*
Have you ever been charged with or convicted of any crime? If yes explain the nature of& dates or charge or conviction /¿Alguna vez ha sido acusado o condenado por algún delito? En caso afirmativo, explique la naturaleza y las fechas de la acusación o condena.
*
List any languages spoken:
*
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Education:
Highest Level of Education/ Nivel educativo más alto
*
Please Select
High School
College
Graduate School
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
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Mandatory Job History / Historial laboral obligatorio
Current Employer Name / Nombre del empleador actual
Current Employer Position / Position
Your job title
Current Employer Start Date /. Fecha que empezó
-
Month
-
Day
Year
Date Picker Icon
Current Employer Location / Ubicacion
i.e. Neighborhood
Current Employer Duties
Please include an in-depth job description
Current Employer May We Contact? / ¿Podemos contactar a su empleador actual?
Yes / Si
No / no
Please explain why we may not contact your current employer:
Previous Employment
Previous Employer
i.e. Name of Family
Previous Employer Position
Your job title
Previous Employer Start Date
-
Month
-
Day
Year
Date Picker Icon
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?
Previous Employer May We Contact?
Yes
No
Please explain why we may not contact your previous employer:
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References / Referencias
Please include at least three
May we contact your references? / ¿Podemos contactar a sus referencias?
Yes / SI
No / No
Reference One / Referencia uno
Name of Reference
Reference One Relationship / Relation
Reference One Years Acquainted / Años de conocerse
Reference One Phone / Telefonica
Reference One Email / Correo Electronico
example@example.com
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Resume:
Please Upload Your Resume (optional)
Upload a File
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