Elder's Ranch By Carla – Employment & Volunteer Application
Complete all applicable sections and avoid including Social Security numbers, medical diagnoses, or copies of identification.
1. Position(s) Applying For
Position(s) Applying For
*
Caregiver
Live-In Caregiver
Part-Time Caregiver
Full-Time Caregiver
Volunteer
2. Applicant Information
Full legal name
*
First Name
Middle Name
Last Name
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
City / State
*
Preferred contact method
*
Phone call
Text message
Email
3. Certifications, Training & Education
Certified caregiver
*
Yes
No
In progress / N/A
Fingerprint clearance card
*
Yes
No
In progress / N/A
Current TB screening / test documentation
*
Yes
No
In progress / N/A
Food handler's card
*
Yes
No
In progress / N/A
Memory care / dementia training
*
Yes
No
In progress / N/A
High school diploma or equivalent (GED)
*
Yes
No
In progress / N/A
CPR certification
*
Yes
No
In progress / N/A
First aid certification
*
Yes
No
In progress / N/A
Other relevant credentials and training
Certification names and expiration dates (if applicable)
4. Caregiving Experience
Years of caregiving experience
*
Describe your experience with seniors, assisted living, or memory care
*
Which caregiving tasks have you performed?
*
Personal care / bathing / dressing
Transfers / mobility assistance
Meal preparation / feeding assistance
Medication assistance within authorized scope
Dementia / memory care
Companionship / activities
Housekeeping / laundry
Care documentation / reporting
5. Physical Requirements & Work Readiness
Can you safely assist with resident lifting, transfers, and repositioning, using appropriate equipment and assistance?
*
Yes
No
In progress / N/A
Do you have reliable transportation to and from work?
*
Yes
No
In progress / N/A
Are you available to work weekends or holidays?
*
Yes
No
In progress / N/A
Are you available for overnight shifts?
*
Yes
No
In progress / N/A
Are you willing to complete additional required training?
*
Yes
No
In progress / N/A
Are you willing to undergo lawful background and credential verification?
*
Yes
No
In progress / N/A
Have you previously worked in an assisted living home?
*
Yes
No
In progress / N/A
Reasonable accommodations may be available. Do not disclose medical conditions on this form.
6. Availability
Earliest available start date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Available days
*
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Preferred shift
*
Morning
Afternoon
Overnight
Live-in
Flexible
Hours available per week
Scheduling restrictions or notes
7. Employment / Volunteer History
Most recent employer / organization
*
Job title
*
Dates employed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for leaving
*
Please Select
Career advancement
Seasonal/temporary work ended
Relocation
Personal reasons
Returned to school
Better fit elsewhere
Other
Previous employer / organization
Main responsibilities
*
8. Professional References
Reference 1 Name
*
First Name
Middle Name
Last Name
Reference 1 Professional relationship / position
*
Reference 1 Phone or email
*
Reference 2 Name
*
First Name
Middle Name
Last Name
Reference 2 Professional relationship / position
*
Reference 2 Phone or email
*
9. Additional Information
Why would you like to work or volunteer at Elder's Ranch By Carla?
*
Anything else you would like to share
10. Applicant Acknowledgment
I certify that the information in this application is accurate and complete to the best of my knowledge. I understand that submitting an application does not guarantee employment or a volunteer placement and that additional verification may be required.
I acknowledge the statement above.
*
I acknowledge the statement above.
Applicant signature
*
Applicant signature (type full name)
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
Should be Empty: