First Name*
Last Name*
Email Address*
Phone*
Cover Letter*
Why do you want to work caring for seniors?*
Do you have access to email to be able to submit your availability and communicate with the office?*
-- No answer -- Yes No
Do you have your own cell phone?*
-- No answer -- Yes No
Many Caregiver assignments require the caregiver to drive to their clients home and also potentially perform errands and transportation for a client . Do you have a valid drivers license and dependable vehicle?*
-- No answer -- Yes No
Please provide the make, model of your car along with your drivers license number and State of issue.*
Work Preferences: Please check all the options that you are interested in.*
-- No answer -- Mornings (7am - 1 pm) Days (9am-6pm) Evenings (3pm-11pm) Night Shifts (9pm - 9am) Sleepshifts (9pm - 9am - able to get 6 hours of sleep) Part Time 6-35 hours per week Full Time 35-44 hours per week
Please indicate what days you are available to work:*
Number of hours you would ideally like to work weekly?*
What geographic area(s) would you like to work in?*
What is your highest level of caregiver training and experience?*
-- No answer -- Caregiver - Limited Experience Caregiver - Extensive Personal Experience SSWG / DSW / CSW / PTA / OTA PSW - or Equivalent ( Nursing Student 1+ year) Nurse - RPN or RN (Licensed) Other
Please elaborate on your formal education. List diploma's/degrees achieved/obtained including year completed.
What training or experience do you have working with the elderly? (Either formal or informal)
What do you like most about working with the elderly?*
What do you like least about working with the elderly?
Have you ever been convicted of an offence for which a pardon has not been granted?*
-- No answer -- Yes No
Professional References: Please list three (3) people (who are not related to you) including prior supervisors who can provide a professional reference.
Personal References: Please list three (3) people (who are not related to you) who can provide a personal reference.
Have any of your relatives ever worked for Seniors Prefer Homecare? Yes/No please include their name(s)
Do / Have any of your friends ever worked for Seniors Prefer Homecare? Yes/No please include their name(s)
Did anyone refer you to the company? Who
Please indicate any languages you can speak, read and/or write. Please include your native language. ie. English - speak/read/write*
Date Available to Start*
Salary or Wage expectations: (hourly)
Provide a summary as to why you think you would make an outstanding addition to our team / caregiver?*
Please provide your level of experience and proficiency in meal preparation for seniors.*
-- No answer -- I have trouble boiling water I can heat up pre-packaged meals - that's about it. I can open a fridge and prepare a standard meal from scratch I am on par with a chef and can prepare anything
Please indicate your level of experience and proficiency in providing the following home maintenance activities for seniors. Vacuuming, Dusting, Cleaning - Bathrooms and Kitchens, Bed Linen Changes, Laundry and Ironing.
-- No answer -- I have no clue where to start. I can do the basics but it is not my thing. I am good at these tasks - but there is room for improvement. I am Mary Poppins and can whip a house into shape in no time.
All clients are different, when it comes to providing companionship, please describe yourself.*
-- No answer -- I am quiet and reserved I can make small talk. I enjoy talking to others and find people open up to me. People open up to me - by the end of the day - I know their life story
Please indicate your level of experience and proficiency in providing the following activities for seniors. Errands, Transportation, Grocery Shopping either for or with a senior client.*
-- No answer -- I have no experience I have some experience but may be uncomfortable in some aspects. I have extensive experience and no issues with respect to this type of assistance. I am not comfortable doing these types of things
We are interested to know how you found us. Please tell us your source below:
CERTIFICATION AND RELEASE: By electronically submitting this application I certify that I have read and understand the application 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 or alcohol is prohibited during employment. Should I report to work intoxicated or found to be using drugs or alcohol while on the job, the company may terminate my employment for serious reasons, without further compensation, notice or delay.*
-- No answer -- Yes No
Would you be willing to take a drug test?*
Do you have car insurance that is current?*