caregiver application

Thank you for your interest in AGELESSHome Care Services.
AGELESS Home Care Services provides experienced, compassionate care to seniors and their families looking for reliable, trustworthy Caregivers. We receive many inquiries each day from people who are interested in qualifying to be on our first-rate care provider team.
To be considered as a team member with AGELESS, the following must be met:

  • Minimum 1+ years of experience providing care within the industry.
  • A dependable vehicle properly insured.
  • Valid State driver’s license.
  • Recent copy of your driver’s license report (within last 6 months).
  • Copy of recent TB (Tuberculosis) screening (within last 6 months) or Cxray if positive
  • Background check completed (Recent LIVE Scan)
  • Any certifications or degrees you may have earned.
  • Minimum of 3 verifiable professional references.
  • Current Medical Clearance
  • I-9 Form (downloadable in internet)

If you can meet all of the above, then completely read and fill out the enclosed Application.
When you have completed the Application, please fax, return by mail or drop off at our office listed
above.
Thank you for your interest.
Sincerely,
AGELESS Home Care Services of California

Your Full Name : (required)

Street Address : (required)

City :

State :

Home Phone :

Cell Phone :

Tax ID /SSN #:

Date Of Birth :(optional)

Ethincity :(optional)

How did you hear about us:

Alternate Contact:

Name :

Phone :

Address :

Relationship :

Are you currently employed / provide Care to others? If Yes, Explain.
 Yes No

Have you ever been convicted of a misdemeanor/felony? If Yes, provide details Yes No

Transportation :
Most clients require transportation, often using the:

Do you have dependable transportation?
 Yes No

Make and model car :

License plate # :

Driver license # :

Insurance company :

Insurance agent name :

Availability:

Appx. hours per week available:

Days/Times you are available :

Days & times not available

Select the areas that you will accept work :

What Education Qualifies You To Work As a:

High School : City/State

College : City/State

Other : City/State

Degrees certificates – All Degrees Or 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 Please:

Companion Care & Safety :
 Yes No

Alzheimer’s :
 Yes No

Dementia :
 Yes No

Meal Prep /Clean Up :
 Yes No

Feeding :
 Yes No

Light Housekeeping :
 Yes No

Laundry :
 Yes No

Medication reminders :
 Yes No

Transportation :
 Yes No

Bathing (Reg.,bed, sponge) :
 Yes No

Dressing/Grooming :
 Yes No

Incontinence :
 Yes No

Ambulation :
 Yes No

Transfer assist :
 Yes No

Oral Care :
 Yes No

Shaving Assistance :
 Yes No

Assist w / P.T. Exercises :
 Yes No

Assist w/Prosthesis :
 Yes No

Hospice :
 Yes No

Willing to Work w/Pets :
 Yes No

Speak fluent English :
 Yes No

Work History:

Please provide at least five years of recent:,

Company :

From :

Job title :

Reason left :

Duties :

Supervisor :

Phone :


Company :

From :

Job title :

Reason left :

Duties :

Supervisor :

Phone :


Company :

From :

Job title :

Reason left :

Duties :

Supervisor :

Phone :

Professional/ Business Reference:

Name :

Address :

Relationship/YearsKnown :

Name :

Address :

Relationship/YearsKnown :

Name :

Address :

Relationship/YearsKnown :

Character & Personal:

Name :

Address :

Relationship/YearsKnown :

Name

Address

Relationship/YearsKnown

Name :

Address :

Relationship/YearsKnown :

CERTIFICATION AND RELEASE:

I certify that I have read and understand the general requirements of Independent Care Contractors/Providers 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 completely understand that I am submitting this Application as an interested Care Provider and that by submitting this there is no guarantee for employment. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, work, criminal and credit history and motor vehicle driving records. I authorize all persons, schools, companies, and

OR

Click the link below to download out caregiver application form.

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