Caregiver Application Form

Caregiver Application Form
Agency Name
Address
Phone
Format: (000) 000-0000.
Email
example@example.com
Section 1: Personal Information
 Full Name
 Date of Birth

MonthDayYear
Date
 Gender
 Address

Street Address Line 2

City/State/ZIPState / Province

Postal / Zip Code
 Phone Number
Format: (000) 000-0000.
 Email Address
example@example.com
 Preferred Contact Method
Section 2: Employment & Availability
 Are you currently employed?
If yes, where?
 Days/Hours Available (Check all that apply)
 Desired Hours per Week
 Can you commit to a consistent schedule?
Section 3: Qualifications & Experience
1. Do you have experience working with individuals with IDD?
o If yes, please describe
2. Are you certified in CPR/First Aid?
o Expiration Date

MonthDayYear
Date
3. Do you have any other relevant certifications or trainings (e.g., ODP mandatory trainings)?
o If yes, please list
4. Do you have a valid driver’s license?
o License Number
o State
o Expiration Date

MonthDayYear
Date
Section 4: Health & Safety
 Are you fully vaccinated for COVID-19?
o If yes, vaccination dates

MonthDayYear
Date
 Do you have any health conditions that may affect your ability to provide care?
o If yes, please describe
 Have you ever been convicted of a felony?
o If yes, please explain
Section 5: References
Please provide at least 2 professional or personal references:
1. Name
Relationship
Phone
Format: (000) 000-0000.
Email
example@example.com
2. Name
Relationship
Phone
Format: (000) 000-0000.
Email
example@example.com
Section 6: Applicant Statement
I certify that all information provided is true and complete. I understand that false information may result in denial of employment or termination. I authorize the agency to verify the information provided, including background checks.
Signature
Date

MonthDayYear
Date
Should be Empty:

Caregiver Application Form

Section 1: Personal Information

Section 2: Employment & Availability

Section 3: Qualifications & Experience

Section 4: Health & Safety

Section 5: References

Section 6: Applicant Statement