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 & Scheduling Preferences
Clinical & Personal Care Experience
Cooking & Meal Prep
Hearing
Language(s) Spoken
Pet Environment & Comfort
Preferred Care Setting
Transportation & Mobility
Wound Care

References   New Reference

Miscellaneous Questions

Q.) How did you hear about this position? (referral, website, etc.)
Q.) Are you at least 18 years old? (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.) If offered employment, are you able to provide documentation verifying your legal eligibility to work in the United States? (Note: Proof of eligibility will be required upon hire.) (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.) 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? (Own car, public transportation, uber, other, etc.)
Q.) How far are you willing to travel for work? (Enter minutes or mileage)
Q.) If applying for a position that will include driving, If hired, can you provide a valid driver license? (YES or NO)
Q.) Are you available to work on weekends? (YES or NO)
Q.) Have you ever filed an employment application with us before? (YES or NO)
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.) Are you proficient with computers and mobile apps? (YES or NO)
Q.) Are you currently employed elsewhere? (please share your workdays and hours)
Q.) Are you Self-Employed? (YES or NO)
Q.) May we contact your current employer to verify the above information you provided? -- All employers including your current employer may be contacted to verify the information you provide.
Q.) Describe your job-related skills and/or training
Q.) Explain any gaps in your employment, other than those due to illness, injury or disability.
Q.) Do you smoke? (YES or NO)
Q.) Do you have any allergies or medical conditions that would affect caregiving duties? (back problems, cannot be around pets, etc.)
Q.) Do you have any religious or cultural restrictions? (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.) 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.) 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".

* Caregiver Signature

© Copyright 2026, Developed and Maintained By CareSmartz360