Caregiver Application

PERSONAL INFORMATION

Your Name*
Address* City*
County* State* Zip*
Home Phone Cell Phone
Own Car? YesNo
Email*
Do You Smoke? YesNo
 
Have you been a resident of Arkansas continuously for the past 5 years? YesNo
 
SPECIALIZED SKILLS, TRAINING, and CERTIFICATES (Crtl-Select all that apply)

WORK PREFERENCES

AVAILABLE FOR LIVE-IN ENGAGEMENTS? (if YES Crtl-Select all that apply)
YesNo
Live-In Options
MINIMUM DAILY FEE YOU WILL ACCEPT $
MINIMUM HOURLY FEE YOU WILL ACCEPT $
AVAILABLE FOR HOURLY ENGAGEMENTS?(if YES Crtl-Select all that apply)
YesNo
ShiftsDays
Other Preferences

PROFESSIONAL EXPERIENCE (list total experience in years for each category)

Hospital Nursing Home Private Companion Setting

WORK HISTORY (start with present, or most recent, engagement)

1. Name of Client/Registry/Other Contact Person Phone
Address Type of Services Performed
Dates of Service: From To Reason Engagement Ended
2. Name of Client/Registry/Other Contact Person Phone
Address Type of Services Performed
Dates of Service: From To Reason Engagement Ended
3. Name of Client/Registry/Other Contact Person Phone
Address Type of Services Performed
Dates of Service: From To Reason Engagement Ended
I understand that if Superior Senior Care agrees to assist me in locating potential clients, I will continue to function as a self-employed caregiver and I will remain responsible for my own personal insurance and for reporting my earnings to the I.R.S. I certify that the foregoing information is true and correct to the best of my knowledge.