Caregiver Applicant Form

Personal Information

* First Name

*Last Name

* Email

* Address Line 1

Address Line 2

* Country

* State/Province

* City

* Zip/Postal Code

*Gender

* Mobile Phone

* Home Phone

*Date of Birth

* SSN

Educational Background New Educational Background

School/College/University

Qualification

Attach Document

Minimum one certificate is mandatory to be filled.

Certifications

Food Handlers Card

Browse

NAR

Browse

CNA

Browse

CPR

Browse

Driver's License

Browse

HCA

Browse

Employment History New Employment History

Please provide your latest employer information below.

Employer Name

Phone Number

Address

Country

State/Province

City

Zip/Postal Code

Served From

Served To

Position Held

Attach Document

References New Reference

Name

Phone Number

Miscellaneous Questions

Q.) How far are you willing to travel for work (minutes)?

Q.) What is your availability? (Please be as specific as possible)

Q.) Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Health/Care and community support agency?

Q.) If offered a position, when you would be available to start?

Q.) What is your expected wage?

Q.) List other languages spoken

Q.) We require a DSHS background check. Please copy and paste the following address into your browser https://fortress.wa.gov/dshs/bcs/. Once complete please provide the code here.

Availability Hourly Live-In Overnight	Cooking Skills Diabetic Diet Puree Gluten Free Instapot	Experience Alzheimer's Anxiety Autism Bed Bath Cancer Combative Dementia Gait Belt Experience Glucose Monitor Hospice Hoyer Lift Experience Incontinence Mental Health Parkinson's Sit to Stand Stroke	Language English Other (List below)
Personal Care Maximum Assistance Pivot Transfers Stand by Assist	Pets Okay with Cats Okay with Dogs	Transportation Caregiver has vehicle Driver License Insured vehicle Non-Driver	Vehicle Type Drive Client Vehicle Vehicle is low-clearance/can transport clients

Caregiver Application Form

Personal Information

Educational Background New Educational Background

Certifications

Employment History New Employment History

Skills/ Preferences

References New Reference

Miscellaneous Questions

* Caregiver Signature