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Caregiver Employment Application

Join Our Care Team

We’re always looking for compassionate, dependable caregivers who want to make a meaningful difference.

Full Name

Phone Number

Address

Email Address

Are you 18 years of age or older? *

Yes

No

Do you have reliable transportation? *

Yes

No

Please check all shifts you are available to work: * Required

24-Hour Live-In Care

Full-Time (40+ hours/week)

Part-Time (under 40 hours/week)

Overnight Shifts

Weekends

Holidays

Please list the days and times you are available to work:

Are you willing to work the following? Emergency/On-call Shifts: *

Yes

No

Are you willing to work the following? Double Shifts (e.g. back-to-back clients) *

Yes

No

How soon are you available to start work?

Do you have any restrictions on the number of hours you can work per week? If yes, please explain:

Are you open to both temporary and long-term assignments? *

Yes

No

Only Temporary

Only Long-Term

Work Eligibility & Background

Are you legally authorized to work in the U.S.? *

Yes

No

Have you ever been convicted of a felony or misdemeanor?

Can you pass a background check and drug screening? *

Yes

No

Do you have a valid driver’s license? *

Yes

No

Do you have current car insurance? *

Yes

No

Do you have a clean driving record? *

Yes

No

Certifications & Training

Do you have any of the following certifications? (Check all that apply) *

CPR/First Aid

CNA (Certified Nursing Assistant)

HHA (Home Health Aide)

PCA (Personal Care Assistant)

Others

When does your CPR/First Aid certification expire?

Are you willing to take additional training if needed? *

Yes

No

Work Experience

How many years of experience do you have in home care or caregiving?

Scenario & Personality Questions

Availability & Preferences
Already discussed, but you can also add:

Are you open to working with male/female clients? *

Yes

No

Do you have any physical limitations (e.g., lifting restrictions)? *

Yes

No

Do you smoke? (Some clients require non-smokers) *

Yes

No

Are you comfortable with pets in the home? *

Yes

No

References

Upload Resume/CV

Upload supported file (Max 15MB)

Background Check (CORI)

Upload supported file (Max 15MB)

Health/Physical Statement

Upload supported file (Max 15MB)

CPR and First Aid Certification

Upload supported file (Max 15MB)

Training Certificates

Upload supported file (Max 15MB)

Fingerprint Check (if required)

Soulful Support Homecare, LLC

PROUDLY SERVING:
SPRINGFIELD • CHICOPEE • HOLYOKE • WEST SPRINGFIELD • LONGMEADOW

413-264-6570

info@soulfulsupporthomecare.org

Contact Information

First name*

Last name

Email*

Address

Phone

Additional information

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