Caregiver Application Form Name(Required) City Home PhoneCell PhoneEmail(Required) Experience Level CNA CHHA Personal Attendant Nursing Student Years Experience In your most recent assignments what have been your job duties? Bathing Dressing Meal Prep Housekeeping Hospice Alzheimer’s/Dementia Transfers Hoyer Lift Rehab Parkinson’s Bed Bound Incontinence Care Do you have a California Drivers License? Yes No Do you have reliable transportation? Yes No What type of transportation? For example, you own a car, take the bus, trolley, etcCan you stoop, bend and lift up to 25 pounds? Yes No How many hours per week are you looking for? What days are you available for Hourly work? Expected Pay Rate Have you worked for a Home Care Agency or Facility? Yes No Which one(s), and for how long were you there?Have you worked privately for clients? Yes No What were your primary responsibilities? Do you have a current TB test or chest X-ray? Yes No Are you current certified in CPR? Yes No Check the areas you are available to work in: San Diego Encinitas South Bay Escondido Clairemont Ocean Side La Jolla Rancho Penasquitos Del Mar Carmel Valley East County Rancho Bernardo Coronado Valley Center Pacific Beach Rancho Sante Fe We do a Criminal Background check. Is anything going to show up on yours? Yes No Please Attach your ResumeAccepted file types: doc, docx, pdf, odf, Max. file size: 15 MB.Allowed formats: MS Word, PDF, plain text
