Caregiver Application

PERSONAL INFORMATION

Your Name
Address
City
State
Zip
Home Phone
Cell Phone
 
Own Car?
 Yes
 No
 
Email
 
Do You Smoke?
 Yes
 No
 
Have you been a resident of Arkansas continuously for the past 5 years?
 Yes
 No
 
SPECIALIZED SKILLS, TRAINING, and CERTIFICATES (Crtl-Select all that apply)

WORK PREFERENCES
AVAILABLE FOR LIVE-IN ENGAGEMENTS? (if YES Crtl-Select all that apply)

 Yes
 No		 Live-In Options

MINIMUM DAILY FEE YOU WILL ACCEPT $
 
AVAILABLE FOR HOURLY ENGAGEMENTS?(if YES Crtl-Select all that apply)

 Yes
 No		 Shifts

 Days
 
Other Preferences
MINIMUM HOURLY FEE YOU WILL ACCEPT $

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.