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Home Care Employment Application
Availability Section
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
Submit
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