Caregiver Applicant Form

Personal Information

* First Name

*Last Name

* Email Invalid Email Format.

* Address Line 1

Address Line 2

* Country

* State/Province

* City

* Zip/Postal Code

*Gender

* Mobile Phone

* Home Phone

*Date of Birth

* SSN

Please enter a valid SSN.

All mandatory fields must be filled.

Educational Background New Educational Background

School/College/University

Qualification

Attach Document

Minimum one certificate is mandatory to be filled.

Certifications

Alien Card

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Notes

Automobile Insurance

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Background Check

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CNA

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CPR

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Notes

Driver's License

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Drug Screening

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Notes

Elder Abuse Training

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Notes

First Aid

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Notes

HHA

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Notes

I9 Verification

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Notes

LPN

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Notes

LVN

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Notes

Passport

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Notes

Professional Liability

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Notes

Professional License

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Notes

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SSN

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Notes

State ID

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Notes

TB Test

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Notes

Work Permit

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Notes

Employment History New Employment History

Please provide your latest employer information below.

Delete Employer Info

Employer Name

Phone Number

Address

Country

State/Province

City

Zip/Postal Code

Served From

Served To

Position Held

Attach Document

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

Skills/ Preferences

Availability

Hourly

Live-In

Cooking Skills

Diabetic

Diet Puree

Gluten Free

Experience

Alzheimer's

Bed Bath

Cancer

Combative

Dementia

Dementia Experience

Gait Belt Experience

Glucose Monitor

Hospice

Hospice Experience

Hoyer Lift Experience

Incontinence

Parkinson's

Stroke

General

Female Caregiver

Male Caregiver

Language

English

Italian

Spanish

Level of Ability

Level I

Level II

Personal Care

Maximum Assistance

Pivot Transfers

Stand by Assist

Pets

Okay with Cats

Okay with Dogs

Transportation

Driver License

Insured vehicle

Non-Driver

Owns Car

Vehicle Type

Accommodates wheelchair

Drive Client Vehicle

Needs Car

All the highlighted fields are mandatory to be filled.

References New Reference

Name

Phone Number

Minimum 1

Miscellaneous Questions

Q.) Availability & Scheduling

Are you available for 12-hour shifts?

Are you willing to do overnight shifts?

What days and times are you available to work?

Q.) Experience & Skills

Do you have experience with transfers or fall-risk clients?

How many years of caregiving experience do you have?

What types of clients have you worked with? (Dementia, Alzheimer’s, Hoyer lift, wheelchair, etc.)

Q.) Certifications & Credentials

Are you fully vaccinated for flu/COVID?

Do you have a valid CNA license?

Do you have CPR/First Aid certification?

Do you have current TB test results?

Q.) Transportation & Travel

Are you open to live-in assignments?

Are you willing to travel to clients in various Chicago and suburban areas?

Do you have a valid driver’s license?

Q.) Work Preferences

Are you comfortable with cameras in the client’s home?

Are you comfortable working with pets?

What type of case do you prefer? (Companion, personal care, dementia, total care)

Q.) Employment & Background

Are you authorized to work in the United States?

Are you willing to undergo a state-required background check and fingerprinting?

Do you have any physical restrictions we should be aware of?

Q.) Have you ever been terminated from a caregiving position? If yes, explain.

Q.) Why did you choose caregiving as a career?

Q.) What makes you a great caregiver?

Q.) What motivates you to stay with a company long-term?

* Caregiver Signature

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