Caregiver Hiring Application

Caregiver Hiring Application
Personal Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name:

First NameLast Name
Emergency Contact Phone:
Please enter a valid phone number.
Position Applying For:

CaregiverCare CoordinatorOther
Available Start Date:

MonthDayYear
Date
Preferred Schedule:

Full-TimePart-TimeWeekdaysWeekendsOvernightOther
Work Eligibility
Are you legally eligible to work in the United States?

YesNo
Do you have a valid driver’s license?

YesNo
Do you have reliable transportation?

YesNo
Experience & Skills
Do you have previous caregiving or healthcare experience?

YesNo
If yes, describe your experience (agencies, roles, years):
Are you comfortable with the following tasks?

Bathing & groomingTransfers & mobility supportMeal prepLight housekeepingMedication remindersCompanionshipWorking with seniorsWorking with individuals with disabilities
Certifications:

CNAHHACPR/First AidDSP CertificationOther
If other please explain:
Background Information
Have you ever been convicted of a felony?

YesNo
(If yes, list details. This does not automatically disqualify you.)
Are you willing to complete a background check?

YesNo
Work History
Position:   Type a label
Supervisor Name:   Type a label
Supervisor Phone:   Type a label
Start Date – End Date:   Type a label
Reason for Leaving:   Type a label
Position:   Type a label
Supervisor Name:   Type a label
Supervisor Phone:   Type a label
Start Date – End Date:   Type a label
Reason for Leaving:   Type a label
Position:   Type a label
Supervisor Name:   Type a label
Supervisor Phone:   Type a label
Start Date – End Date:   Type a label
Reason for Leaving:   Type a label
References

(Professional or personal, no family members)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship:
Additional Information
Is there anything else you would like us to know?
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Should be Empty:

Caregiver Hiring Application

Personal Information

Work Eligibility

Experience & Skills

Background Information

Work History

References

Additional Information