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| Many caregiver positions require the caregiver to transport a client. |
| How far are you willing to drive to provide care for a client? Please list cities. |
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| Degrees/certificates |
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| Special skills or courses |
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| Discuss any training or experience working with the elderly |
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| What would you like most about working with the elderly? |
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What would you like least about
working with the elderly? |
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| Please indicate whether you have assisted with or performed the following tasks for seniors. |
| Companion-ship |
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| Bathing/ dressing |
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| Grooming |
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| Incontinence |
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| Transfer assist |
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| Vacuuming |
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| Dusting |
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| Clean bathrooms |
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| Clean kitchen |
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| Bed linen changes |
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| Laundry |
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| Grocery shopping |
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| Cooking |
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| Driving |
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| Medication reminders |
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| Please go back at least five years and tell us about your work history. Use reverse side of sheet if additional space is required. |
| May we contact your current
employer? |
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I certify that I have read and understand the application note 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 understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal 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. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. |
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