Caregiver Application Form

Personal Information
*
*
*
*
*
*
*
*
*
*
*
*
*

Educational Background  New Educational Background

Employment History  New Employment History

Please provide your latest employer information below.

Completion of a minimum of one skill/preference is required.

Skills/ Preferences

Availability
Cooking Skills
Experience
General
Hearing
Language
Level of Ability
Locations
Personal Care
Pets
Preferred Shift
Transportation
Vehicle Type
Wound Care

References   New Reference

Miscellaneous Questions

Q.) How did you hear about us?
Q.) Are you at least 18 years old? (YES or NO)
Q.) How did you hear about us?
Q.) This job may require you to transfer up to 75 pounds from/to a bed, commode, couch, wheelchair, etc. Are you able to perform this duty? (yes or no)
Q.) How many years of experience do you have as a Caregiver?
Q.) You may be required to get a Background/LiveScan, will this be a problem? (YES or NO)
Q.) Are you authorized to work in the U.S. (do you have a Social Security)? (YES or NO)
Q.) This job may require you to transfer up to 75 pounds from/to a bed, commode, couch, wheelchair, etc. Are you able to perform this duty? (YES or NO)
Q.) All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status or any other protected classification, in accordance with applicable federal, state, and local laws. By completing this application, you are seeking to join a team of hardworking professionals dedicated to consistently delivering outstanding service to our customers and contributing to the financial success of the organization, its clients, and its employees. Equal access to programs, services, and employment is available to all qualified persons. Those applicants requiring accommodation to complete the application and/or interview process should contact a management representative at (310) 450-0660. --My PRINTED FULL NAME below certify that the answers given by me on this application are true and correct to the best of my knowledge. PLEASE PRINT FULL NAME BELOW
Q.) What City do you live in? (Please be more specific than writing LOS ANGELES or provide ZIP CODE)
Q.) How do you get to work?
Q.) How far are you willing to travel for work?
Q.) What days are you available for work? (Day, Night, or Open)
Q.) Are you available to work on weekends? (YES or NO)
Q.) What licenses or credentials do you have? (Please list them)
Q.) If offered the position, how soon would you be able to start? (Please write a date)
Q.) Why do you think you would be a great addition to our Care Team?
Q.) All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status or any other protected classification, in accordance with applicable federal, state, and local laws. By completing this application, you are seeking to join a team of hardworking professionals dedicated to consistently delivering outstanding service to our customers and contributing to the financial success of the organization, its clients, and its employees. Equal access to programs, services, and employment is available to all qualified persons. Those applicants requiring accommodation to complete the application and/or interview process should contact a management representative at (310) 450-0660. --My PRINTED FULL NAME below certify that the answers given by me on this application are true and correct to the best of my knowledge. PLEASE PRINT FULL NAME BELOW
Q.) EMPLOYMENT-AT-WILL STATEMENT: I acknowledge that my employment is at will and for no specific duration. Either I or the company may terminate my employment at any time, with or without cause or prior notice. My employment-at-will status cannot be changed except in writing signed by the president of the company. --PLEASE CONFIRM THAT YOU UNDERSTAND THIS BY TYPING BELOW "I UNDERSTAND".
Q.) PLEASE NOTE: YOU ARE REQUIRED TO COMPLETE ALL FIELDS IN THE APPLICATION TO BE CONSIDERED FOR WORK -- PLEASE CHECK EVERYTHING BEFORE SUBMITTING. THANK YOU! Do you have any questions for us?
Q.) Are you tech savvy? (YES or NO)
Q.) Are you currently employed elsewhere? (please share your workdays and hours)
Q.) Are you Self-Employed? (YES or NO)

* Caregiver Signature

© Copyright 2025, Developed and Maintained By CareSmartz360