Job Application Form

Lighthouse Caregivers Application
Full Name*

First NameLast Name
Your maiden name*
Birth Date*

MonthDayYear
E-mail*
Phone Number*

Area CodePhone Number
How did you hear about us?
EmployedUnemployedSelf-EmployedStudent
Do you have a resume? Upload it here.

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We love pictures! Please upload a profile picture of yourself.*

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Tell us about your desires as a caregiver. How would you help a senior in need of care?*
Are you eligible to work in the U.S*
Do you drive?*
Do you have a car to get to work?*
Available start date:*

MonthDayYear
Part-timeFull-timeLive-InHourlyWeekdaysWeekendsOther
SaturdaySundayMondayTuesdayWednesdayThursdayFriday
Please let us know if you have specific times when you are available
High SchoolGEDSome CollegeAA DegreeCompleted CollegeOther
No certificationCurrently in schoolCNALVNRNHHACPRFirst AidOther
Have you ever been convicted of a crime? If yes, please tell us about it.*
If we consider you for hire, will you agree to a criminal background check?*
How many years have you worked as a caregiver?
I have never worked as a caregiverI have helped family members, friends and loved onesPrivate resident's homeCare homeRetirement/Senior FacilityAgencyCounty In-Home Support ServicesHospital(s)Other
Safe transfer procedureAssisted Daily Living CareSpecial Diet PreparationProper bathing procedureModerate Alzheimer/DementiaHospice Level CareDiabetic CareStroke Patient CareWheelchair assistanceMS Patient CareDiaper ChangeOxygen MachineCatheter CareG-Tube CareLight HousekeepDeep Cleaning HousekeepPet Care (feed pets, walk dogs, clean litter)
We perform a thorough reference check. Please provide 3 professional references which pertain to your experience as a caregiver. We suggest that you provide 3 families whom you have helped, preferably family members who oversee the care. Supervisors are also accepted references.

If you have no experience as a caregiver, please provide 3 professional references, i.e. your supervisors.
Reference #1: (Please provide name and phone number)*
Date and duties at this assignment
Reference #2: (Please provide name and phone number)*
Date and duties at this assignment
Reference #3 (Please provide name and phone number)*
Date and duties at this assignment
Please press submit to send your application immediately. We will review and contact you as soon as possible.
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Lighthouse Caregivers Application