Application Form -

Application Form

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Step 4

Full Name

Street Address

City

State

Zip

Home Phone

Cell Phone

TAX Id

Do You Smoke?

Yes No

Date of Birth

Ethnicity (Optional)

How did you hear about us?

Craigslist Online Classified Penny Saver Acorn Church Senior Center CalJOBS Posting Board

Are you currently employed / provide Care to others?

Yes No

If Yes, Please explain.:

Transportation

Most clients require transportation, often using the Care Provider’s vehicle:

Do you have dependable transportation?:

Yes No

If Yes Make & Model:

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

Thousand Oaks/Newbury Park Westlake Village Ventura Oxnard Agoura Hills Camarillo Simi Valley Moorpark

What Education Qualifies You To Work As a Caregiver?

High school

City/State

Dates

College

City/State

Dates

Other

City/State

Date of Birth

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

Companion Care & Safety

Yes No

Medication reminders

Yes No

Oral Care

Yes No

Alzheimer’s

Yes No

Transportation

Yes No

Shaving Assistanc

Yes No

Dementia

Yes No

Bathing (Reg.,bed, sponge)

Yes No

Assist w / P.T. Exercises

Yes No

Meal Prep / Clean Up

Yes No

Dressing/ Grooming

Yes No

Assist w/ Prosthesis

Yes No

Feeding

Yes No

Incontinence

Yes No

Hospice

Yes No

Light Housekeeping

Yes No

Ambulation

Yes No

Willing to Work w/Pets

Yes No

Laundry w/Pets

Yes No

Transfer assist

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

From

Job Title

Reason Left

Supervisor

Phone

Duties

Company

From

Job Title

Reason left

Supervisor

Phone

Duties

Company

From

Job Title

Reason Left

Supervisor

Phone

Duties

Why Do You Feel You Would Be An Excellent Addition to Our 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 #

Signature: (TYPE IN ALL CAPS )

Date

The form was sent successfully.

An error occured.

[field id="name"]

[field id="Street Address"]

[field id="City"]

[field id="State"]

[field id="Zip"]

[field id="Home Phone"]

[field id="Cell Phone"]

[field id="TAX Id"]

[field id="DoYouSmoke"]

[field id="dob"]

[field id="ethnicity"]

[field id="about_us"]

The form was sent successfully.

An error occured.

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 #

Signature: (TYPE IN ALL CAPS )

Date

The form was sent successfully.

An error occured.

[field id="name"]

[field id="Street Address"]

[field id="City"]

[field id="State"]

[field id="Zip"]

[field id="Home Phone"]

[field id="Cell Phone"]

[field id="TAX Id"]

[field id="DoYouSmoke"]

[field id="dob"]

[field id="ethnicity"]

[field id="about_us"]

Skills

Companion Care & Safety

Yes No

Medication reminders

Yes No

Oral Care

Yes No

Alzheimer’s

Yes No

Transportation

Yes No

Shaving Assistanc

Yes No

Dementia

Yes No

Bathing (Reg.,bed, sponge)

Yes No

Assist w / P.T. Exercises

Yes No

Meal Prep / Clean Up

Yes No

Dressing/ Grooming

Yes No

Assist w/ Prosthesis

Yes No

Feeding

Yes No

Incontinence

Yes No

Hospice

Yes No

Light Housekeeping

Yes No

Ambulation

Yes No

Willing to Work w/Pets

Yes No

Laundry w/Pets

Yes No

Transfer assist

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

From

Job Title

Reason Left

Supervisor

Phone

Duties

Company

From

Job Title

Reason left

Supervisor

Phone

Duties

Company

From

Job Title

Reason Left

Supervisor

Phone

Duties

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

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

Thousand Oaks/Newbury Park Westlake Village Ventura Oxnard Agoura Hills Camarillo Simi Valley Moorpark

What Education Qualifies You To Work As a Caregiver?

High school

City/State

Dates

College

City/State

Dates

Other

City/State

Date of Birth

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?

Full Name

Street Address

City

State

Zip

Home Phone

Cell Phone

TAX Id

Do You Smoke?

Yes No

Date of Birth

Ethnicity (Optional)

How did you hear about us?

Craigslist Online Classified Penny Saver Acorn Church Senior Center CalJOBS Posting Board

Are you currently employed / provide Care to others?

Yes No

If Yes, Please explain.:

Transportation

Most clients require transportation, often using the Care Provider’s vehicle:

Do you have dependable transportation?:

Yes No

If Yes Make & Model:

License plate #

Driver license #

Auto insurance policy #

Insurance company

Insurance agent name

Insurance agent phone