Caregiver Application Form

Personal Information
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Educational Background  New Educational Background

Employment History  New Employment History

Please provide your latest employer information below.

Skills/ Preferences

Availability
Cooking Skills
Experience
General
Language
Level of Ability
Personal Care
Pets
Skill Type
Transportation
Vehicle Type

References   New Reference

Miscellaneous Questions

Q.) Are you looking for full or part time work?
Q.) When can you start?
Q.) Valid drivers license?
Q.) Do we have your permission to run a background check?
Q.) This job requires that you [list physical activity like heavy-lifting]. Do you have any medical conditions to prevent you from performing tasks like these?
Q.) Are you willing to adjust your schedule or pick up extra shifts on occasion?
Q.) Where was your last job?
Q.) For how long did you work there?
Q.) Can we contact your last employer?
Q.) Past employers name and phone number
Q.) Tell me about your past experience and how it relates to this position?
Q.) With what kinds of people have you worked (disabled, elderly, ethnicities, etc.)?
Q.) How do you feel about people who are older/have disabilities?
Q.) What education or special training qualifies you for this position?
Q.) Why are you interested in this position and home care work in general?
Q.) We would like to hire someone for the long term. How does this fit with your plans?
Q.) Have you had to handle an emergency before? If so, what was it and what did you do?
Q.) How would your best friend describe you?
Q.) What do you think will be the most difficult part of the job?
Q.) What kind of food do you know how to cook?
Q.) How do you go about planning or preparing a meal?
Q.) Any other comments?
Q.) Do you smoke tobacco products?
Q.) If not, are you comfortable being in an environment with someone who smokes?
Q.) Do you use marijuana?

* Caregiver Signature

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