Caregiver Application

Thank you for your interest in Ageless Home Care of California.

AGELESS Home Care Services provides experienced, compassionate care to seniors and their families looking for reliable, trustworthy Caregivers. We receive many inquiries each day from people who are interested in qualifying to be on our first-rate care provider team.
To be considered as a team member with AGELESS, the following must be met:

  • Minimum 1+ years of experience providing care within the industry.
  • A dependable vehicle properly insured.
  • Valid State driver’s license.
  • Recent copy of your driver’s license report (within last 6 months).
  • Copy of recent TB (Tuberculosis) screening (within last 6 months) or Cxray if positive
  • Background check completed (Recent LIVE Scan)
  • Any certifications or degrees you may have earned.
  • Minimum of 3 verifiable professional references.
  • Current Medical Clearance
  • I-9 Form (downloadable in internet)

If you can meet all of the above, then completely read and fill out the enclosed Application.
When you have completed the Application, please fax, return by mail or drop off at our office listed
above.
Thank you for your interest.
Sincerely,
AGELESS Home Care Services of California

    Your Full Name : (required)

    Street Address : (required)

    City :

    State :

    Home Phone :

    Cell Phone :

    Tax ID /SSN #:

    Date Of Birth :(optional)

    Ethincity :(optional)

    How did you hear about us:

    Alternate Contact:

    Name :

    Phone :

    Address :

    Relationship :


    Are you currently employed / provide Care to others? If Yes, Explain.
    YesNo


    Have you ever been convicted of a misdemeanor/felony? If Yes, provide detailsYesNo

    Transportation :
    Most clients require transportation, often using the:

    Do you have dependable transportation?

    YesNo

    Make and model car :

    License plate # :

    Driver license # :

    Insurance company :

    Insurance agent name :

    Availability:

    Appx. hours per week available:

    Days/Times you are available :

    Days & times not available

    Select the areas that you will accept work :

    What Education Qualifies You To Work As a:

    High School : City/State

    College : City/State

    Other : City/State

    Degrees certificates – All Degrees Or Certificates must be presented copy.
    All will be verified with provider/issuer.

    Special skills or courses – Any skills that assist in making you qualified as a professional Care Provider.

    What is Your Past Experience?:

    Discuss any training or experience working with the elderly. How are you trained and/or experienced in working with the elderly?

    What do YOU do that shows and proves you’re Reliable, Trustworthy and Honest?
     

    What would you like least about working with the elderly?
     

    Skills Please:

    Companion Care & Safety :
    YesNo

    Alzheimer’s :
    YesNo

    Dementia :
    YesNo

    Meal Prep /Clean Up :
    YesNo

    Feeding :
    YesNo

    Light Housekeeping :
    YesNo

    Laundry :
    YesNo

    Medication reminders :
    YesNo

    Transportation :
    YesNo

    Bathing (Reg.,bed, sponge) :
    YesNo

    Dressing/Grooming :
    YesNo

    Incontinence :
    YesNo

    Ambulation :
    YesNo

    Transfer assist :
    YesNo

    Oral Care :
    YesNo

    Shaving Assistance :
    YesNo

    Assist w / P.T. Exercises :
    YesNo

    Assist w/Prosthesis :
    YesNo

    Hospice :
    YesNo

    Willing to Work w/Pets :
    YesNo

    Speak fluent English :
    YesNo

    Work History:

    Please provide at least five years of recent:,

    Company :

    From :

    Job title :

    Reason left :

    Duties :

    Supervisor :

    Phone :

    Company :

    From :

    Job title :

    Reason left :

    Duties :

    Supervisor :

    Phone :

    Company :

    From :

    Job title :

    Reason left :

    Duties :

    Supervisor :

    Phone :

    Professional/ Business Reference:

    Name :

    Address :

    Relationship/YearsKnown :

    Name :

    Address :

    Relationship/YearsKnown :

    Name :

    Address :

    Relationship/YearsKnown :

    Character & Personal:

    Name :

    Address :

    Relationship/YearsKnown :

    Name

    Address

    Relationship/YearsKnown

    Name :

    Address :

    Relationship/YearsKnown :

    CERTIFICATION AND RELEASE:

    I certify that I have read and understand the general requirements of Independent Care Contractors/Providers on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I completely understand that I am submitting this Application as an interested Care Provider and that by submitting this there is no guarantee for employment. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, work, criminal and credit history and motor vehicle driving records. I authorize all persons, schools, companies, and