Caregiver Application Form

Your Full Name *

Date *

Street Address *

Email *

City *

Province

Postal Code

Home Phone *

Cell Phone

Tax ID/SSN #

Do you smoke?

Yes

No

Date of Birth

Ethnicity (Optional)

How did you hear about us?

Alternate Contact

Name *

Phone *

Address

Relationship

Are you currently employed / provide Care to others? Yes No

Have you ever been convicted of a misdemeanor/felony? Yes No

Transportation
Most clients require transportation, often using the Care Provider's vehicle

Do you have dependable transportation?

Yes

No

Make and model car

License plate #

Driver license #

Auto insurance policy #

Insurance company

Insurance agent name

Insurance agent phone

Availability

Appx. hours per week available

Days/Times you are available

Days & times not available

Can you be called at the last minute in case of emergency?

Yes

No

Select the areas that you will accept work
Toronto Brampton Mississauga Vaughan Other

What Education Qualifies You To Work As a Caregiver?

High school

City/Province

Dates

College

City/Province

Dates

Other

City/Province

Dates

Degrees/certificates – All Degrees / Certificates must be presented copy. All will be verified with provider/issuer.

Special skills or courses – Any skills that assist in making you qualified as a professional Care Provider.

What is Your Past Experience?

Discuss any training or experience working with the elderly. How are you trained and/or experienced in working with the elderly?

What do you do that shows and proves you're Reliable, Trustworthy and Honest?

What would you like least about working with the elderly?

Skills
Please indicate which of the following skills you are prepared to provide if referred to seniors / families

Companion Care & Safety

Yes

No

Medication reminders

Yes

No

Alzheimer's

Yes

No

Transportation

Yes

No

Dementia

Yes

No

Bathing (Reg., bed, sponge)

Yes

No

Meal Prep / Clean Up

Yes

No

Dressing/ Grooming

Yes

No

Feeding

Yes

No

Incontinence

Yes

No

Light Housekeeping

Yes

No

Ambulation

Yes

No

Laundry

Yes

No

Transfer assist

Yes

No

Oral Care

Yes

No

Shaving Assistance

Yes

No

Assist w / P.T. Exercises

Yes

No

Assist w/ Prosthesis

Yes

No

Hospice

Yes

No

Willing to Work w/Pets

Yes

No

Speak fluent English

Yes

No

Work History
Please provide at least five years of recent, verifiable work history followed by verifiable references.

Company 1

From

To

Job title

Reason left

Duties

Supervisor

Phone

Company 2

From

To

Job title

Reason left

Duties

Supervisor

Phone

Company 3

From

To

Job title

Reason left

Duties

Supervisor

Phone

Why Do You Feel You Would Be An Excellent Addition to Our Dearest Home Team?

Business | Professional References

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Character & Personal References

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

CERTIFICATION AND RELEASE

I certify that I have read and understand the general requirements of Independent Care Contractors/Providers on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I completely understand that I am submitting this Application as an interested Care Provider and that by submitting this there is no guarantee for employment. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, work, criminal and credit history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

Name of Applicant *

Date