New Customer Registration Form

  • Comfort Keepers® in Lancaster, CA Pre-Screening Form

  • Applicant Details:

     
  • Format: (000) 000-0000.
  • Have you previously been employed by Comfort Keepers?*
  • Are you at least 18 years of age?*
  • Do you have both a valid Drivers License and vehicle insurance?*
  • Some clients may require caregivers who can communicate in languages other than English. Please answer the following: Are you bilingual or multilingual?*
  • Pre‑employment requirements for this role include a criminal background check, driving record check, and drug screening/TB test. Please confirm whether you can complete these requirements.*
  • Do you have at least 2 years of experience working with seniors?*
  • Do you have any experience providing personal care (Ex: Bathing; Grooming; toileting; Incontinence care)?*
  • Are you trained in working with ​clients who have dementia?*
  • Are you comfortable working with Male and Female clients?*
  • We service the Greater Antelope Valley and surrounding areas. Are you willing and able to commute a minimum of 20 miles?*
  • Occasionally, we may assist clients with transportation to doctor's appointments or running errands. Do you feel comfortable driving clients in your own vehicle?*
  • Are you able to assist clients with transfers, and lift at least 25 pounds?*
  • Are you registered with the Home Care Aide Registry (HCA)?*

  • Provide your availability for each day of the week, including start and end times for each day you can work.

    Caregivers are expected to be available a minimum of one weekend day, with holiday availability as needed per the client's needs. If you are only available for overnights, format your availability timeframes as (pm-am).
  • Are you available on Sunday(s)? If so, please provide the timeframe below.*
  • Until
  • Are you available to work overnights on Sunday(s)?*
  • Are you available on Monday(s)? If so, please provide the timeframe below.*
  • Until
  • Are you available to work overnights on Monday(s)?*
  • Are you available on Tuesday(s)? If so, please provide the timeframe below.*
  • Until
  • Are you available to work overnights on Tuesday(s)?*
  • Are you available on Wednesday(s)? If so, please provide the timeframe below.*
  • Until
  • Are you available to work overnights on Wednesday(s)?*
  • Are you available on Thursday(s)? If so, please provide the timeframe below.*
  • Until
  • Are you available to work overnights on Thursday(s)?*
  • Are you available on Friday(s)? If so, please provide the timeframe below.*
  • Until
  • Are you available to work overnights on Friday(s)?*
  • Are you available on Saturday(s)? If so, please provide the timeframe below.*
  • Until
  • Are you available to work overnights on Saturday(s)?*
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