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Personal Information
Full Legal Name
Preferred Name
Phone Number
Email Address
Street Address
City
State
ZIP Code
Emergency Contact Name & Phone
Preferred Pronouns
Are you at least 18 years old?
Yes
No
Are you legally authorized to work in the U.S.?
Yes
No
Health & Physical Requirements
Do you have any physical limitations that may affect your ability to perform job duties?
No
Yes
Are you able to lift 50 pounds or more if required?
Yes
No
Are you comfortable assisting individuals with hygiene and mobility needs?
Yes
No
Education & Training
Highest Level of Education Completed
Name of School / Institution
Graduation Year
Relevant Certifications
CPR / First Aid
CNA / HHA
CPI / Crisis Intervention
Mandated Reporter Training
Are you willing to participate in further training?
Yes
No
Work Experience
Have you worked in a caregiving role before?
Yes
No
If yes, describe your experience
Past Employers (up to 3)
Employer Name
Job Title
Dates Employed
Key Duties
Reason for Leaving
Supervisor Contact
May we contact them?
Yes
No
Employer 2
Employer Name
Job Title
Dates Employed
Key Duties
Reason for Leaving
Supervisor Contact
May we contact them?
Yes
No
Employer 3
Employer Name
Job Title
Dates Employed
Key Duties
Reason for Leaving
Supervisor Contact
May we contact them?
Yes
No
Transportation & Availability
Do you have a valid driver’s license?
Yes
No
Do you have access to reliable transportation?
Yes
No
Do you have auto insurance?
Yes
No
Are you willing to drive clients if needed?
Yes
No
What days/hours are you available to work?
Available for Weekends?
Yes
No
Available for Overnights?
Yes
No
Available for On-call / Emergencies?
Yes
No
Interested in Live-in Care?
Yes
No
Skills, Preferences & Scenarios
Why do you want to work with people with disabilities?
Populations you’ve worked with
What makes you a good fit for this role?
How do you handle challenging behavior?
Describe a time you showed patience or compassion in a care role.
Tasks you’re uncomfortable performing
Languages spoken (besides English)
References
Reference 1 - Name
Reference 1 - Relationship
Reference 1 - Phone or Email
Reference 1 - Years Known
Reference 2 - Name
Reference 2 - Relationship
Reference 2 - Phone or Email
Reference 2 - Years Known
Background & Declarations
Have you ever been convicted of a crime?
No
Yes
Are you listed on any abuse registries or have caregiving restrictions?
No
Yes
Are you willing to undergo a background check?
Yes
No
Are you willing to take a TB test / drug screening if required?
Yes
No
How did you hear about this job?
Additional Notes or Comments
Applicant Agreement
I certify that all answers are true and complete to the best of my knowledge.
Signature
Date
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Cover Letter
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