"Matching Seniors and Independent Caregivers is Our Only Business!"
 

Caregiver Quick App

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Caregiver Quick Application
 

Note: Our quick Application form is designed to collect some basic information to get the process started. Please Note: You are still required to download and fill out full application and also provide a minimum of 2 professional references to be considered for employment.

Name: *

Last Name: *

Address: *

Phone: *

Email: *

Date of Birth: *

Where were you born?



Have you worked as a private pay caregiver before?:


How many years have you worked as a Private Pay Caregiver?





Last Pay Rate:    $

What Certificate/Degree do you hold? Please check all that apply.


CNA CHHA NA LVN RN
CPR Hospital/Facility Trained None

Other

I have cared for clients with the following:(Please check all that apply)



Alzheimer's/Dementia Cancer Stroke
Hospice DiabetesParkinson's
 Brain Injury
Paraplegia, Quadriplegia
Psychiatric and emotional issues

When can you start?


Please check days you are available to work:

Mon Tues Wed Thurs Fri
Sat Sun
 

Work Preference:





Shift Preference:



Do you smoke?



Do you mind if client smokes?



Do you mind if client owns pets ie., dog, cat?



Are you ok with driving client to appointments or running errands?





When driving client around I prefer to drive:
 
 
Would you describe yourself as outgoing or quiet?


 
Outgoing- I love to talk and entertain others
Quiet -I am quiet, more reserved and laid back
A little of both- depends on my mood

Which personality traits best describes you? 
 
QuietPunctualYouthfulMature (40+)
Social Aggressive Playful Passive
Forthright Shy Energetic Serious
Sarcastic Funny Bubbly Anxious
Sensitive Bold
How Did You Hear About Us?:
Comments:

 
***Please Note: We will review your application and contact you within one week of receipt.
Please Do Not Call!