Elderly Care Application Contact Number (required) Email (required) Work Areas Rural AreasCitySmall Town Are you willing to work in the following in the above areas? Date of Availability Please enter the date that you'll be available. Expected Wage Personal Information Your Name (required) Address Date of Birth Martial Status Children How many children do you have? Ages Please give the ages of your children Status Home Child Care Provider Pilot or the Home Support Worker PilotOpen work permitLanded immigrantCitizen What is your status here? How long have you been here? Date of Arrival General Information Education Do you smoke? YesNo Do you own a driver's license? YesNo Do you have access to a car? YesNo Do you rely on public transit? YesNo Do you know first aid training? YesNo Do you know CPR training? YesNo Are you willing to get the following: First Aid TrainingCPR TrainingPolice Background Check Driving Record Cooking Skills PoorAverageGoodExpert Are you able to prepare any of the following cuisine? AmericanEuropeanChineseOther Can you swim? YesNo Are you allergic to pets? YesNo What languages can you speak? EnglishTagalogIlocanoVisayanCantoneseMandarinSpanishOther English is the major language in here. On a scale of 1 to 10, how do you rate your abilities: Verbal Communication Listening Comprehension Other Skills Employment History Employer #1 Name Employer #1 Contact Number Date of Employment Address May we contact this employer? YesNo Ages of elderly you cared for Reason for leaving Employer #2 Name Employer #2 Contact Number Date of Employment Address May we contact this employer? YesNo Ages of elderly you cared for Reason for leaving Employer #3 Name Employer #3 Contact Number Date of Employment Address May we contact this employer? YesNo Ages of elderly you cared for Reason for leaving Please answer the following questions briefly Please, check all that apply. Experience with elderly/patient that had: AlzheimersParkinsonDiabetesPalliative Care / Wheelchair transportOsteoporosisDepressionDementiaAutismMultiple SclerosisChronic Obstructive Pulmonary diseaseOther On a scale of 1-10 how do you rate the following attributes and your work ethics towards the elderly you are looking after: Loyalty Honesty Passion Reliability Responsibility Hardworking Do you agree to send the above information? I hereby swear that the above information is correct and authorize, Reliable Nanny & Caregiver Placement Agency to verify my information. Δ
