Caregiver Application Form

This form allows us to gather basic information which can be used to effectively match you with suitable client families.

Basic Data

First Name: *

Last Name: *

Email Address:

Phone Number - WhatsApp: *

Alternate Phone Number:

Location: *

Location Detail: *

Shift Preference

Availability:

8 - Hour

12 - Hour

24 - Hour

Overnight

Live-In

Weekend Daily

Weekend Overnight

Experience

Diseases:
(tick all applicable answers)

Alzheimer's Disease

Bed Ridden Patients

Cancer

Dementia

Diabetes

Injury

Insulin Administration

Stroke

Other Experience:

How many years of experience do you have as a caregiver? *

Additional Info

Are you comfortable with pets?

Are you comfortable with cooking and meal preparation?

Do you have a driver's license?

Do you own a car or have access to a vehicle?

Training & Qualifications

Please specify the institutions and qualifications you have received or programs you have completed.

Institutions:

Qualifications:

Programs:

Certifications:

References - Private/In-Home Care

Please provide the name and contact number for previous employers. If possible, please provide references for in-home/private family care.

We only accept references who you have been employed by in a professional capacity. Please DO NOT list friends or family members etc. We will disregard any references that you have not directly worked with.

Reference 1: Name: *

Reference 1: Contact Number: *

Reference 2: Name: *

Reference 2: Contact Number: *

Emergency Contact

Please provide a name and contact number for someone we can get in touch with in case of an emergency.

Full Name:

Phone Number:

Relation:

Other

Anything else you would like to inform us about?

Notes: