Caregiver Application Online Caregiver Registration 1. PERSONAL INFORMATION:Name* First Last Phone*Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you eligible for work in the United States of America:*YesNo2. LICENSURE & PROFESSIONAL TRAININGLicenses held* FL-RN FL-LPN FL-CNA HHA Certificate Companion Caregiver (Check all that apply)FL-RN Number*FL-LPN Number*FL-CNA Number*HHA Certificate issued by*(Name of School or Institution)HHA hours*FL-RN Expiration Date* Date Format: MM slash DD slash YYYY FL-LPN Expiration Date* Date Format: MM slash DD slash YYYY FL-CNA Expiration Date* Date Format: MM slash DD slash YYYY If Companion Caregiver, please describe your experience.*3. WORK REFERENCES:(In-home care related references)Name of Employer*City*State*Phone*FaxStart Date* Date Format: MM slash DD slash YYYY Finish Date* Date Format: MM slash DD slash YYYY Name of Employer*City*State*Phone*FaxStart Date* Date Format: MM slash DD slash YYYY Finish Date* Date Format: MM slash DD slash YYYY 4. WORK AVAILABILITYMondays* Morning Afternoon Overnight Live-In Not Available Tuesdays Morning Afternoon Overnight Live-In Not Available Wednesdays* Morning Afternoon Overnight Live-In Not Available Thursdays* Morning Afternoon Overnight Live-In Not Available Fridays* Morning Afternoon Overnight Live-In Not Available Saturdays* Morning Afternoon Overnight Live-In Not Available Sundays* Morning Afternoon Overnight Live-In Not Available 6. SPECIFIC EXPERIENCE(You may be asked to discuss this at interview)Diagnosis Experience Alzheimer’s / Dementia Seizures COPD Parkinson’s Stroke ALS Diabetes Multiple Sclerosis Para / Quadriplegic Mobility Ambulation Supervision Walker Supervision Transferring Gait Belt Hoyer Lift Physical Therapy Personal Care: Bathing Dressing Toileting Incontinence Colostomy / Urinary Catheter Skin / Wound Care Vital Signs Medication Assistance Hospice Household Tasks: Companionship Food Preparation Grocery Shopping Transportation (your vehicle) Light Housekeeping Pet Care Exercise Guidance Organizing Activities Appointment Scheduling 7. ADDITIONAL QUESTIONSHave you ever been convicted of a felony?*YesNoHave you had a car accident or moving violation in the past 3 years?*YesNoFinally, and most importantly, what makes you a fantastic caregiver?*
