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

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.) Do you have any DSP experience? If so, where, how long, and what were your responsibilities?

Q.) Are you able to work your shift with clients outside the client(s) home?

Q.) Have you ever been terminated from a previous caregiver role/job? If yes, why?

Q.) Do you currently give care to or know an individual with a Medicaid waiver that would be willing to come with you to Duty of Hope? (Referral Bonus)

Q.) Are you authorized to work in the United States?

Availability Evening Shift Hours (5 PM - 1 AM) Hourly Live-In Morning Shift Hours (9 AM - 5 PM) Overnight Shift Hours (12 AM - 8 AM)	Diet/Cooking Skills Diabetic Diet Puree Gluten Free Vegan/Vegetarian	Equipment Communication Device Experience Hearing Aid Assistance Hoyer Lift Mobility Aid Device Orthotic and Prosthetic devices	Experience Administering Medication Alzheimer's Bathing Assistance Behavioral Support Dressing Feeding Gait Belt Glucose Monitor Hospice Hoyer Lift Incontinence Non-Verbal Person-Centered Planning Stroke Toileting Walking Assistance Wheelchair Transfers
General Female Client Male Client	Language English Italian Spanish	Personal Care Emotional Support/Companionship Feeding Hair Care Maximum Assistance Nair Care Oral Hygiene Pivot Transfers Stand by Assist Toileting Assistance	Pets Okay with Birds Okay with Cats Okay with Dogs
Transportation Driver License Insured vehicle Non-Driver Owns Car	Vehicle Type Modified Vehicle Standard Vehicle

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