Caregiver Application

Full Name

Email Address

Physical Address

City, State, Zip

Phone

Are you over 18 years of age?

Yes

No

Are you legally eligible to work in the United States? *

Yes

No

Please list all days and hours you are available to work.

How flexible are you to cover shifts and substitute for teammates, outside of your regular work schedule?

Highly Flexible

Somewhat Flexible

Rarely Flexible

Never Flexible

Our night shifts are awake shifts. If applying for a night shift, do you foresee any difficulty remaining awake and alert for the entire shift?

Yes

No

N/A

Do you have reliable transportation?

Yes

No

Date Available to Start

Expected Salary?

This position requires working some holidays and may require overtime, weekend work, and staying on shift until your relief arrives. Do you foresee any problems fulfilling these requirements?

Yes

No

If “Yes”, please explain.

Are you able to work the following shifts?

Days: 7am – 3pm

Yes

No

Swings: 3pm – 11pm

Yes

No

NOC: 11pm – 7am

Yes

No

PRN

Yes

No

If you have any plans/appointments in the next three months that would conflict with your work schedule, please provide important information.

Employment History

Are you currently employed?

Yes

No

Text

Please list present and past employment starting with your most recent employer:

1. Employer/Company Name

Dates Employed

Supervisor’s Name

Supervisor’s Contact Info

Can we contact this employer?

Yes

No

2. Employer/Company Name

Dates Employed

Supervisor’s Name

Supervisor’s Contact Info

Can we contact this employer?

Yes

No

3. Employer/Company Name

Dates Employed

Supervisor’s Name

Supervisor’s Contact Info

Can we contact this employer?

Yes

No

Education

Please list present and past education starting with the most recent school:

1. Name of School

Field of Study

Certification or Degree Earned

Year of Completion

2. Name of School

Field of Study

Certification or Degree

Year of Completion

3. Name of School

Field of Study

Certification or Degree

Year of Completion

Skills & Abilities

Are you restricted from lifting specific weights?

Yes

No

Have you dealt with incontinence (both bowel and bladder) and used incontinence products on any of your previous jobs?

Yes

No

This job requires you to transfer residents from bed to wheelchair and from wheelchair to bed or toilet or chair. Do you have any physical limitations that would prohibit you from task?

Yes

No

Is there any phase of housekeeping that you cannot do or are unwilling to do?

Yes

No

If "Yes", please explain.

How would you describe your housekeeping skills (laundry, cleaning bathrooms, floors, etc.)?

How would you describe your skills in preparing meals/cooking?

What other skills/abilities do you have that pertain to this position?

References

1. Name

Relation

Email

Phone Number

2. Name

Relation

Email

Phone Number

3. Name

Relation

Employee Credentials

Check the boxes of your current credentials:

What else would you like us to know about yourself?

To the best of my knowledge, the information I have provided in this application is true and accurate. I
understand that if I am offered a job with your company, accept it, and later it is determined that my answers to
any of the above questions are not truthful; I may be dismissed from employement.

Electronic Signature *

Date of Signature *

How did you hear about this open position? *

If other, please specify

Email

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