Caregiver Applicant Form

Personal Information

*First Name

*Last Name

* Email

* Address Line 1

Address Line 2

* Country

* State

* City

* Zip Code

*Gender

* Mobile Phone

* Home Phone

* SSN

Educational Background New Educational Background

School/College/University

Qualification

Employment History New Employment History

Please provide your latest employer information below.

Employer Name

Phone Number

Address

Country

State

City

Zip Code

Served From

Served To

Attach Document

References New Reference

Name

Phone Number

Miscellaneous Questions

Q.) What position are you applying for?

Q.) As a part of the application process for Strategic Health & Wellness Solutions you understand that this agency may conduct an investigation of your personal information to include names/dates of current/previous employment, work experience, workers compensation claims, criminal history records, motor vehicle records, names and dates of education, credit and bankruptcy records. In addition, you understand these records may be used for eligibility of employment. Any false statements provided will be considered just cause for termination of employment. Do you authorize without reservation full release of these records and certify that all information provided on your application/resume is correct to the best of your knowledge? Yes or No

Q.) Have you ever been convicted of a felony?

Q.) Current or desired pay?

Q.) May we contact your previous employers?

Q.) Available start date?

Q.) What is your availability?

Availability Hourly Live-In	Cooking Skills Diabetic Diet Puree Gluten Free	Experience Alzheimer's Bed Bath Cancer Combative Dementia Dementia Experience Gait Belt Experience Glucose Monitor Hospice Hospice Experience Hoyer Lift Experience Incontinence Parkinson's Stroke	General Female Caregiver Male Caregiver
Language English Italian Spanish	Level of Ability Level I Level II	Personal Care Maximum Assistance Pivot Transfers Stand by Assist	Pets Okay with Cats Okay with Dogs
Transportation Driver License Insured vehicle Non-Driver Owns Car

Caregiver Application Form

Personal Information

Educational Background New Educational Background

Certifications

Employment History New Employment History

Skills/ Preferences

References New Reference

Miscellaneous Questions