Caregiver Application
Name
First Name
Middle Name
Last Name
Phone Number
E-mail
example@example.com
If applying for a specific position, list the job title here:
Total number of years experience in caregiving:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Check all that apply:
Passion for caregiving
Knowledgeable about personal care
Able to pass a background check
Valid Drivers License
Clear driving record
Safe & insured vehicle
Can legally work in the U.S.
Reliable and Punctual
Coachable
Valid TB test results (
Current CPR certification
Can work in a home with pets
Can work in a home with a smoker
Are you 18 years of age or older?
Yes
No
Are you authorized to work In The United States?
Yes
No
Are you currently living in the Greater Indianapolis Area?
Yes
No
Please select the areas you are open to working in
Downtown Indianapolis
Beech Grove
Brownsburg
Forest Manor area
Plainfield
Broad Ripple
Avon
Castleton
Camby
Greenfield
Speedway
Fountain Square / Southside
College Park / Pyramids Area
Greenwood
Carmel
Fishers
Distance Willing To Travel?
Please Select
Over 30 Mile Radius
Below 30 Mile Radius
Public Transit Only
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Relevant Information
Date You Can Start
-
Month
-
Day
Year
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Salary Desired
Position Interested In (check all that apply):
Full Time
Part Time
Temporary
On Call
Do you have a conviction (misdemeanor or felony) for any theft related crimes, including, but not limited to, shoplifting, criminal conversion, burglary, robbery, attempted robbery, identity theft, embezzlement, check forgery, petty theft, grand theft, larceny, fraud, receiving stolen property, carjacking, etc. This does not include any crime that has been successfully expunged. We are only asking about crimes still on your record.
Please Select
Yes, I have a conviction for a theft related crime
No, I do not have a conviction for a theft crime
If you answered "YES" to the theft crime question, please explain below:
State law prohibits any home care agency from employing or contracting with any person who has been convicted of a crime involving theft, battery, murder, manslaughter, sex crime, exploitation of an endangered adult, abuse or neglect of a child and failure to report battery, neglect, or exploitation of an endangered adult or dependent. We perform a Nationwide background check. Do you currently have any conviction (misdemeanor or felony) for any of the aforementioned crimes that would bar you from working or contracting as a caregiver? This does not include any crime that has been successfully expunged. We are only asking about crimes still on your record.
Please Select
Yes, I have one or more of these convictions
No, I do not have any of these convictions
If you answered "YES" to the criminal background question, please explain below:
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Skills/Qualifications:
Why do you want to be a caregiver for the elderly?
List three words that describe your personality:
What skills and experience do you have that are useful in the role of a caregiver? Feel free to be as in depth as possible.
CPR/First Aid Certified?
Please Select
Yes
No
No but Willing to Get Certified
Our personal Care Assistants help clients their personal hygiene as part of their role. The amount of assistance will vary from client to client but may include, bathing, assisting with bathing, assisting with oral hygiene, assisting with combing hair, assisting with applying lotion and deodorant and dressing. Do you understand this is part of the job and are you willing to perform these duties if hired?
Please Select
Yes, I understand & willing to perform these duties
No, I don't understand and/or not willing to perform these duties
Our personal Care Assistants may have to help a client with their toileting. This includes assisting to and from the bathroom, assisting with clean up, assisting with Depends or diapers, assisting with bedside commodes, etc. Do you understand this is part of the job and are you willing to perform these duties if hired?
Please Select
Yes, I understand & willing to perform these duties
No, I don't understand and/or not willing to perform these duties
Our personal Care Assistants perform light housekeeping to support our clients in maintaining a clean, hygienic, and safe home. Light housekeeping will include washing dishes, sweeping, mopping, vacuuming, dusting, cleaning and sanitizing bathrooms, changing bed linen, doing laundry, taking out trash, etc. Do you understand this is part of the job and are you willing to perform these duties if hired?
Please Select
Yes, I understand & willing to perform these duties
No, I don't understand and/or not willing to perform these duties
Our personal Care Assistants help clients with their nutrition as part of job responsibilities. This includes, but not limited to, meal planning, meal prepping, cooking, plating the food, grocery shopping, visiting pantries, etc. PCAs are expected to prepare hot meals for clients as part of their duties. Do you understand this is part of the job and are you willing to perform these duties if hired?
Please Select
Yes, I understand & willing to perform these duties
No, I don't understand and/or not willing to perform these tasks
List any additional relevant training, including caregiving training, health & safety training, dementia training, culinary training, etc.
Anything else you would like to share:
Include links to your social media profiles, so we can get to know you better:
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Education:
High School
Name of High School Attended
Graduated High School?
Please Select
Yes
No
No but obtained my High School Equivalency (HSE/GED)
College
Name of College/University Attended
College Status?
Please Select
Completed 1 year
Completed 2 years
Completed 3 years
Completed 4 years
Graduated with Associates Degree
Graduated with Bachelors Degree
List of other professional training, licenses or certifications:
i.e. Home Health Aide, CNA, LPN, Medical Assistant, etc.
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Mandatory Job History
Employer #1
i.e. Name of Family
Position
Your job title
Employer Start Date
-
Month
-
Day
Year
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Employer End Date
-
Month
-
Day
Year
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Duties and Responsibilities
Please include an in-depth job description
Reason for Leaving
Employer #2
i.e. Name of Family
Position
Your job title
Start Date
-
Month
-
Day
Year
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End Date
-
Month
-
Day
Year
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Duties and Responsibilities
Please include an in-depth job description
Reason for Leaving
Employer #3
i.e. Name of Family
Position
Your job title
Start Date
-
Month
-
Day
Year
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End Date
-
Month
-
Day
Year
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Duties and Responsibilities
Please include an in-depth job description
Reason for Leaving
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References:
Please include at least three
Reference One
Name of Reference
Reference One Phone
Reference One Email
example@example.com
Reference Two
Name of Reference
Reference Two Phone
Reference Two Email
example@example.com
Reference Three
Name of Reference
Reference Three Phone
Reference Three Email
example@example.com
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Attachments
Optional: Please Upload Your Cover Letter
Upload a File
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Optional: Please Upload Your Resume
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Optional: Upload Copies of any Professional Certifications or Licenses you hold
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Optional: Please Upload Copy of your CPR Certification
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Optional: Please Upload Copy of your TB Skin Test Results
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Optional: Please Upload Proof of Auto Insurance
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I certify to Careworthy that the information provided on this employment application are true and complete to the best of my knowledge, and I consent Careworthy in processing personal data about me for purposes related to my employment. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my termination of employment.
Please Select
Yes, I understand
Applicant Signature
Submission
Submission
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