Caregiver Applicant Form

Personal Information

* First Name

*Last Name

* Email

* Address Line 1

Address Line 2

* Country

* State

* City

* Zip Code

*Gender

* Mobile Phone

* Home Phone

*Date of Birth

* SSN

Educational Background New Educational Background

School/College/University

Qualification

Attach Document

Employment History New Employment History

Please provide your latest employer information below.

Employer Name

Phone Number

Address

Country

State

City

Zip Code

Served From

Served To

Position Held

Attach Document

References New Reference

Name

Phone Number

Miscellaneous Questions

Q.) Are you at least 18 years old? (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.) How many years of experience do you have as a Caregiver?

Q.) You may be required to get a LiveScan/Fingerprint, will this be a problem? (YES or NO)

Q.) What is your experience as a Caregiver? (please provide as much detail as possible)

Q.) Do you have any questions for us?

Q.) Why do you feel we should hire you?

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.) 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.) Which animal (Owl or Shark) would you choose and why?

Availability Escorting Hourly Live-In	Cooking Skills Basic Diabetic Diet Puree Gluten Free	Experience Activities of Daily Living (ADLs) Alzheimer's Autism Bed Bath Cancer Catheter Chronic Obstructive Colostomy Care Combative Dementia Dementia Experience Diabetics Enema Application Feeding Gait Belt Experience Glucose Monitor G-Tube Hip Surgery Hospice Hospice Experience Hospital Bed (Elec./Manual) Hoyer Lift Experience Hygiene Incontinence J-Tube Learning Disabled Light Housekeeping Medication Reminders Nebulizer Non-Ambulatory Oxygen Tank Parkinson's Pulmonary Disease (COPD) Quadriplegic Range of Motion (ROM) Re-positioning Showering Stand-up Life (SARA Lift) Stroke Transferring Vital Signs Walk Patients Wound Care	General Female Caregiver Male Caregiver
Hearing Hard of Hearing Wears hearing aids	Language English Italian Japanese Russian Spanish Tagalog - Filipino	Level of Ability Level I Level II	Locations Facility Hospital Private Home
Personal Care Maximum Assistance Pivot Transfers Stand by Assist	Pets Okay with Cats Okay with Dogs	Preferred Shift Day Shift Weekdays Day Shift Weekends Flexible Schedule (can work anytime/day) Night Shift Weekdays Night Shift Weekends	Transportation Driver License Insured vehicle Non-Driver Owns Car
Vehicle Type Accommodates wheelchair Drive Client Vehicle Needs Car	Wound Care Level 1 Level 2 Level 3

Caregiver Application Form

Personal Information

Educational Background New Educational Background

Certifications

Employment History New Employment History

Skills/ Preferences

References New Reference

Miscellaneous Questions

* Caregiver Signature