• Caregiver Application

    Independent Contractor (Pool)

  • Thank you for your interest in joining our caregiver network.

    As an existing employee, you’ll be among the first considered when new clients are matched with caregivers, based on availability, location, and client preferences.

    Submissions are reviewed, and qualified applicants may be added to our caregiver pool.

    Please note:

    • Being added to the pool does not guarantee work
    • You will be contacted only if a suitable assignment becomes available
    • If you need more time, please use the Save button to save your progress and return later
       

     Click Start to begin your application.

  • Thank you for your interest in joining our caregiver network.

    This application is for 1099 Independent Contractor opportunities. Submissions are reviewed, and qualified applicants may be added to our caregiver pool.

    Please note:

    • Being added to the pool does not guarantee work
    • You will be contacted only if a suitable assignment becomes available
    • As a 1099 contractor, you are not an employee and are responsible for your own taxes and insurance
    • You will be required to upload your resume as part of this application
    • If you need more time, please use the Save button to save your progress and return later
       

     Click Start to begin your application.

  • Contact Information

  • Format: (000) 000-0000.

  • Demographics

  • Gender*
  • Race*

  • Caregiver Screening

  • Have you been convicted of any of any driving offenses in the past 5 years?*
  • Please Check All that Apply*

  • Caregiver Screening

  • Have you been convicted of any of the following criminal offenses in the past 5 years?:*
    Rows

  • Caregiver Screening

  • Have you EVER been convicted of any of the following?*
    Rows

  • Caregiver Screening

  • Are you able to work as an independent contractor (1099)?*
  • Do you own a smartphone or tablet for documentation?*

  • Caregiver Screening

  • Are you available to work weekends or evenings if needed?*
  • Can you provide care in homes that have pets (cats/dogs)?*

  • Caregiver Screening

  • Can you commit to accepting a minimum of 10 hours per week?*
  • Are you comfortable using apps for clocking in/out, communicating, and documenting care?*

  • Caregiver Screening

  • Languages Spoken Fluently*

  • Caregiver Screening

  • Do you have reliable transportation?*
  • Counties you are willing to travel to? (Check all that apply)*

  • Education & Experience

  • Education*

  • Education & Experience

  • Are you CPR/First Aid certified?*
  • Do you have CNA, PCW or related certification/training?*
  • PCW, CNA, Other Certifications*

  • PCW Questionnaire

  • Please answer the following questions honestly regarding your physical abilities to perform the tasks commonly required of personal care workers:

  • Are you able to lift or transfer clients who may weigh up to 50 pounds or more?*
  • Can you stand and walk for extended periods (up to 6-8 hours per shift)?*
  • Are you comfortable providing personal hygiene care (bathing, dressing, toileting) to clients of various physical abilities?*
  • Can you assist clients in walking, using a wheelchair, or transferring from bed to chair?*
  • Are you comfortable working with clients who may have limited mobility, chronic illnesses, or disabilities?*
  • Are you comfortable reading care plans that outline detailed steps to follow for each client’s specific needs?*
  • How comfortable are you working with clients who have behavioral or mental health conditions (such as anxiety, depression, dementia, or developmental disabilities)?*
  • Are you comfortable reading care plans that outline detailed steps to follow for each client’s specific needs?*

  • Professional References

  • Please provide the names and contact information of at least 3 professional references who can speak to your qualifications, work ethic, and experience. At least one reference should be a current or former supervisor.*

  • Caregiver Profile

  • Please write a short professional profile that we may use to introduce you to potential clients on our website or in client materials.


    Your profile should include:
     

    • Your caregiving experience (how long you’ve worked and types of clients served)

    • Certifications or specialties (CNA, PCW, CPR, dementia care, etc.)

    • A few personal traits or values (e.g., compassionate, reliable, patient)

    • Languages spoken (if applicable)

    • Anything else you’d like clients to know

    Example:

    Hello! My name is Maria and I’ve been a caregiver for over 5 years, assisting seniors and individuals with disabilities. I am a certified CNA with CPR and First Aid training. I specialize in dementia care and pride myself on being dependable, kind, and respectful. I speak both English and Spanish and strive to help clients feel comfortable and safe in their homes.

  • 0/1000

  • If you’d like to include a photo with your caregiver profile, please upload a clear, friendly headshot. This is optional and not required to complete your application.

  • Resume

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  • Applicant Attestation and Consent

    By submitting this application, I certify that all information I have provided is true, accurate, and complete to the best of my knowledge.

    I understand that providing false or misleading information may disqualify me from being considered for the caregiver pool or result in removal if discovered later.

    I further understand and consent that, as part of the application and screening process, the agency may obtain the following reports:

    • Criminal background check
    • Motor Vehicle Record (MVR) check
    • Credit history check


    I authorize the agency and any authorized third-party service provider to conduct these screenings and to use the results to determine my eligibility for assignments.

    I acknowledge that submitting this application does not guarantee work or placement, and that any future assignments are offered at the discretion of the agency based on client needs and qualifications.

  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: