Caregiver Employment Application
RequiredRequired Question(s)
Required 1.

Position you are applying for:

 

Caregiver
Administrative
Other  
Required 2.

Please enter your personal contact information so that we can contact you to discuss your application.


First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Required 3.

Are you currently employed?

No
Yes, please share more about your current employment:
  • Comment:

  • 500 characters left.
Required 4.

Do you have recent, industry, experience as a caregiver?

No
Yes
5.

Please briefly explain your experience:

 

1000 characters left.
6.

What was your most rewarding experience as a caregiver?

 

1000 characters left.
7.

What was your worst experience as a caregiver?

 

1000 characters left.
Required 8.

Time commitment desired:

Full time
Part time
Required 9.

What is your availability on MONDAYS?
(check all that apply)

Morning
Afternoon
Evening
12 hours daytime
12 hours nighttime
24 hours
Not Available
  • Comment:

  • 500 characters left.
Required 10.

What is your availability on TUESDAYS?
(check all that apply)

Morning
Afternoon
Evening
12 hours daytime
12 hours nighttime
24 hours
Not Available
  • Comment:

  • 500 characters left.
Required 11.

What is your availability on WEDNESDAYS?
(check all that apply)

Morning
Afternoon
Evening
12 hours daytime
12 hours nighttime
24 hours
Not Available
  • Comment:

  • 500 characters left.
Required 12.

What is your availability on THURSDAYS?
(check all that apply)

Morning
Afternoon
Evening
12 hours daytime
12 hours nighttime
24 hours
Not Available
  • Comment:

  • 500 characters left.
Required 13.

What is your availability on FRIDAYS?
(check all that apply)

Morning
Afternoon
Evening
12 hours daytime
12 hours nighttime
24 hours
Not Available
  • Comment:

  • 500 characters left.
Required 14.

What is your availability on SATURDAYS?
(check all that apply)

Morning
Afternoon
Evening
12 hours daytime
12 hours nighttime
24 hours
Not Available
  • Comment:

  • 500 characters left.
Required 15.

What is your availability on SUNDAYS?
(check all that apply)

Morning
Afternoon
Evening
12 hours daytime
12 hours nighttime
24 hours
Not Available
  • Comment:

  • 500 characters left.
Required 16.

How far are you willing to travel to a client's home?

5 miles
15 miles
25 miles
Required 17.

If the job requires it, do you have a valid driver's license?

No
Yes
  • Comment:

  • 500 characters left.
Required 18.

Have you had any moving violations in the last 3 years?

No
Yes. Please explain:
  • Comment:

  • 500 characters left.
Required 19.

Have you been convicted of/or plead guilty to a crime?

No
Yes. Please explain:
  • Comment:

  • 500 characters left.

Education

 
Required 20.

Do you have a high school diploma or GED?

No
Yes
Required 21.

Did you attend college?

No
Yes. Please specify the number of years you have attended:
1-2 years
3-4 years
4+ years
Required 22.

Do you have a college degree?

No
Yes. Please define:
  • Comment:

  • 500 characters left.
Required 23.

Do you have any professional licenses?

No
Yes. Please define:
  • Comment:

  • 500 characters left.
Required 24.

Do you have any professional certificates?

No
Yes. Please define:
  • Comment:

  • 500 characters left.