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At Home Personal Care Caregiver Application

Please select the AT HOME PERSONAL CARE location you are applying to:
Title:
Name: First Last
Address
Address

City

State / Province / Region

Postal / Zip Code
Phone Number: - (###) - ### ####
Alt. Phone Number: - (###) - ### ####
Email:
Date of birth: / MM / DD YYYY
Position Desired: Companion Caregiver/Homemaker Personal Care Assistant (P.C.A.) Certified Home Health Aide (C.H.H.A.) Cerified Nursing Aide (C.N.A.) Live-in Caregiver (will sleep overnight at client's home)
Which of the following certifications do you currently have: Personal Care Assistant (P.C.A.) Certified Home Health Aide (C.H.H.A.) Cerified Nursing Aide (C.N.A.)
Do you desire a Full or Part-Time Position? Full-time Part-time (flexible schedules may be available)
Please indicate the schedule you would prefer and your availability: Weekdays only Weekends only Flexible: available weekdays and weekends Day shift hours only Night shift hours only Flexible to work day shift and night shift hours Live-In (24 hour Shifts)
Please check the number of years you have worked as a professional caregiver (those with no experience are also encouraged to apply): No professional experience working as a caregiver, only personal experience Less than 1 year 1 Year 2 + Years 10+ Years
Please indicate if you are Male or Female: Male Female
Other schedule requirements:
List any communicable diseases or health problems you have:
List any physical limitations you may have:
List any medications you are taking:
Please indicate the minimum hourly or daily pay you will accept. Pay varies by geographic area and all agencies offer competitive pay for their location, with various pay increases or bonuses available. Please indicate pay range: Hourly:

Live-In:
What was your pay at the last assignment?
Please indicate any languages you speak besides English: Spanish Italian French Polish Chinese Mandarin Filipino Swahili Vietnamese Farsi Greek Russian OTHER
Please check all of the certifications you have completed within the last 2 years and specializations you could provide: CPR Certification First Aid Certification Two-Step TB Skin Test Multi-state Background Check Basic Life Support Certification (BLS) Able to work with Clients who own cats Able to work with clients who own dogs Able to work with terminal clients on hospice service Able to work with clients who smoke
Do we have your permission to run a background check? Yes No
After reviewing the job description, is this the type of position you are looking for? Yes No
Are you comfortable with the duties required for the position? Yes No
Do you have a Valid Driver's License? Yes No
Do you own a car or have access to a car to drive? Yes No
How far would you be willing to travel from your home to an assignment?
Please list your experiences with the elderly/disabled - make your application standout - we encourage you to share a personal or professional experience you have had as a caregiver.
Tell me about your past experience and how it relates to this position?
Why are you interested in this position and home care work in general?
Have you had to handle an emergency before? If so, what was it and what did you do?
If the client is looking for the long term care. How does this fit with your plans?
List names and phone numbers of 3 non-related people with whom we can verify your work experience: Name Phone
How did you hear about At Home Personal Care? Google YAHOO! Bing Website Link Social Media (Facebook, Twitter, etc) Friend Advertisement Certified Nursing Aide School Backpage.com Craigslist College/C.N.A. School Referral Other
IMPORTANT: PLEASE BRING TWO FORMS OF I.D. WITH YOU TO YOUR INTERVIEW.
EXAMPLES OF ACCEPTABLE I.D.’S INCLUDE A SOCIAL SECURITY CARD, RESIDENT ALIEN CARD AND/OR UTAH DRIVER’S LICENSE / ID CARD.
Please bring copies of any letters of recommendation or certification you have to your interview.
By signing this application I agree to voluntarily submit to any drug and/or alcohol screening requested by AT HOME PERSONAL CARE at any time before, during or up to 30 days after my employment.
I certify to the best of my knowledge that the above information is complete and true.
Online Signature (PRINT YOUR FULL LEGAL NAME):

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At Home Personal Care Caregiver Application

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