Caregiver Application Online Caregiver Registration 1. PERSONAL INFORMATION:Name* First Last Phone*Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you eligible for work in the United States of America:* Yes No 2. 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* MM slash DD slash YYYY FL-LPN Expiration Date* MM slash DD slash YYYY FL-CNA Expiration Date* 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* MM slash DD slash YYYY Finish Date* MM slash DD slash YYYY Name of Employer* City* State* Phone*FaxStart Date* MM slash DD slash YYYY Finish Date* 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?*
