Caregiver Application Form

Personal Information
*
*
*
*
*
*
*
*
*
*
*
*
*

Educational Background  New Educational Background

Employment History  New Employment History

Please provide your latest employer information below.

Skills/ Preferences

Availability
Language
Transportation

References   New Reference

Miscellaneous Questions

Q.) How many years of caregiving experience do you have?
Q.) What populations have you worked with? (e.g., elderly, individuals with disabilities, mental health, children, etc.)
Q.) What certifications or licenses do you currently hold? (e.g., CPR, First Aid, CNA, DSP)
Q.) Have you ever been trained in person-centered or trauma-informed care?
Q.) How do you handle behavioral challenges or emotional outbursts?
Q.) Are you comfortable managing medications or following care plans?
Q.) How do you ensure the dignity and independence of the people you care for?
Q.) Have you ever been convicted of a crime (excluding minor traffic violations)?

* Caregiver Signature

© Copyright 2025, Developed and Maintained By CareSmartz360