Application Form

Step 1 of 3

33%

Instagram

This field is for validation purposes and should be left unchanged.

Job Title: Caregiver - Homemaker/Personal Care /Companion

Reports to: Registered Nurse/ Care Supervisor/ Care Coordinator

Purpose: To provide companionship, homemaking, and light housekeeping services in clients' homes.

Qualifications:

● Provide valid driver's license

● Pass Level 2 background and drug tests (if needed)

● CNA License or complete HHA Exam administered by the agency

● Negative TB test

● CPR/BLS Cards

● Provide CNA/HHA required CE units

● Good communication skills and emotional resilience

● Physical ability to lift/transfer clients and perform repetitive movements

Home Care Services/Responsibilities:

Personal Care – bathing, dressing, hygiene, toileting, grooming (hair brushing, makeup, filing nails but not clipping nails), transferring, feeding, ambulation.

Companionship – provide emotional support, meaningful activities, conversation.

Light Housekeeping – dishes, bedroom, bathroom, laundry, sweep/vacuum, trash.

Meal Preparation – heating meals, cutting up vegetables, cooking basic meals.

Medication Reminders – monitoring and medication reminders.

Transportation – assist with arranging transportation to appointments or accompany clients to appointments or outings.

Errands & Shopping – pick up groceries, pharmacy pickups.

Pet Care & Walking Assistance – feed their pets, letting pets out, cleaning litter boxes.

Reporting Incidents and Behavioral Changes – maintaining accurate work records and reporting incidents and behavioral changes.

Note: Duties and qualifications may evolve.

Job Requirements Approved:

Date

MM slash DD slash YYYY

Title / Name

Signature

Application for Employment

Name

Last

First

Middle

Date

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone #

Cell Phone #

E-Mail Address

Referred to us by

Position(s) applied for

Caregiver

Nursing

Other

Date available

MM slash DD slash YYYY

Type of employee desired

Full-Time

Part-Time

On-Call

Live-In Shift

Please Specify Days and Hours you are available:

MON

TUE

WED

THUR

FRI

SAT

SUN

If currently employed, may we contact your employer?

Yes

Rate of Pay Expected Per Hour ($)

Are you legally eligible for employment in this country?

Yes

Are you available to work overtime if required?

Yes

Have you applied with this company before?

Yes

Do you have any friends or family employed at this location?

Yes

Have you been convicted of a crime in the last seven (7) years?

Yes

If yes, please explain

CONVICTION WILL NOT NECESSARILY BE A DISQUALIFICATION FOR EMPLOYMENT

Do you have the following:

CNA / HHA

Yes

Last Certified

CPR / First Aid

Yes

Last Certified

TB: PPD/Chest X-Ray

Yes

Last Certified

Level 2 Background

Yes

Last Certified

Driver’s License/Other Government Issued IDs

Yes

Last Certified

The CEU’s listed below are required and be obtained online:

HIV and AIDS (CEU)

Yes

Last Certified

HIPAA (CEU)

Yes

Last Certified

Bloodborne Pathogens, Infection Control (CEU)

Yes

Last Certified

Alzhemer’s and Dementia-related disorders (CEU)

Yes

Last Certified

Domestic Violence Training (CEU)

Yes

Last Certified

Residents Rights (CEU)

Yes

Last Certified

Medical Records Documentation (CEU)

Yes

Last Certified

Medical Error Preventions and Safety (CEU)

Yes

Last Certified

Communication with cognitively impaired (CEU)

Yes

Last Certified

Assistance with self-administration of Medication

Yes

Last Certified

I certify that all the information I have provided is true, complete and correct.

The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process.

The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.

I authorize the employer to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal.

I understand that if I am hired, I will be required to provide a criminal background check, proof of identity and legal authority to work in the US, proof of certifications or educational qualifications, and a driver abstract (if applicable).

Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.

Signature

Date

MM slash DD slash YYYY

Thank you for your interest in joining Charisms Care Specialist LLC.

Before submitting your application, please take a moment to carefully review all sections to ensure that the information provided is accurate, complete, and up to date.

Once you have verified that all information is correct, please email any required supporting documents to hello@charismscarespecialists.org .

A member of our team will contact you shortly to schedule a virtual interview.

We look forward to welcoming you to the Charisms Care Specialist LLC team!

Warm regards,

Charisms Care Specialist LLC

CAPTCHA

Application Form

Job Title: Caregiver - Homemaker/Personal Care /Companion

Qualifications:

Home Care Services/Responsibilities:

Application for Employment

Book Now

Let's Talk