Caregiver Application Form

Caregiver Application Form

The starting rate for new caregivers is $15 an hour, with steady increases over time. After you fill out this form, we'll get back to you within two business days as to whether there's a fit. Accepted caregivers will be given a contract and training materials. Afterwards, we'll send placements directly to your email, where you'll get to choose what works for your schedule. Your information here is confidential and can be changed in the future. Thank you for applying!
Full Name*

First NameMiddle NameLast Name
Email Address*
We'll send new jobs directly to this email.
Phone Number*
Question 1: Have you attained a high school diploma?*

YesNo
Question 2: Are you legally permitted to work in Illinois?*

YesNo
Question 3: Do you have previous experience as a caregiver? (we offer training materials and sessions to all new caregivers)*

YesNo
Question 4: Are you willing to help seniors in the following areas? (you can check multiple boxes, services are provided within reason)*

Meal preparationCleaningDriving & errandsPlaying gamesHelp with bathingMedication reminders
Question 5: What is your maximum daily time committment?*

Between 4 and 6 hours a dayBetween 6 and 8 hours a dayMore than 8 hours a day
Question 6: What's the earliest you can reliably work? (this helps with scheduling, you can change this later)*

No scheduling conflictsBy 9:30amBy 10:30amBy 11:30amOther (specify in additional comments please)
Question 7: What's the latest you can reliably work? (this helps with scheduling, you can change this later)*

No scheduling conflictsBy 3:00pmBy 4:00pmOther (specify in additional comments please)
Question 8: Which counties would you be open to working in? (you can change this later, please check all that apply)*

CookLakeWillDupageMcHenryKaneKendallGrundy
Question 9: Which days of the week would you prefer to work? (this helps us best accommodate your schedule, please check all that apply)*

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Additional Comments: (optional)
Should be Empty: