Caregiver (Elderly / Disabled) Application

Please attach your resume at the bottom of this form: (Click to acknowledge)
Contact Information
First Name:
Middle Name:
Last Name:
Gender:	Male Female
Date of birth:	Month Day Year
Email Address:
How did you hear about our agency / web site:

Address 1:
Address 2:
City:
Province:
Country:
Nationality:
Postal/Zip Code:
Day Number:
Evening Number:
Profile Image
Main Photo:
Photo 2:
Photo 3:
Why a family should choose you as their caregiver?
Please give a description of why a family should choose you. This is given to potential families and is available on the website when a family searches for you.

What job are you looking for?
Live-in or Live-out:	Live-in Live-out

Full-time or part-time:	Full-time Part-time

Caregiver for the Elderly:
Caregiver for the Disabled:
What province would you like to work in?
Specify Provinces:
Please area (Town) would you like to live in?
1st Choice:
2nd Choice:
3rd Choice:

Preferred start date:	Month Day Year Or ASAP
Weekly salary desired:
Can you make a one year commitment?	Yes No
Are you legally able to work in Canada?	Yes No
What is your status in Canada?	Canadian Citizen Landed Immigrant Live-in caregiver program Other
If Other: (please specify)

Education
High School Date graduated:	Month Day Year
College / University:
City / Country:
Years attended:
Date graduated:	Month Day Year
Degree:
Education Type:
Special courses attended:
Height:
Weight:
What languages do you speak?

Do you have a driving license?	Yes No
Can you drive automatic:
Can you drive standard:
Do you own a car that you would want to bring with you?	Yes No
Have you had any traffic tickets or auto accidents?	Yes No
Please explain:

Do you swim?	Yes No
Are you certified in CPR?	Yes No
Date:	Month Day Year
First aid?	Yes No
Date:	Month Day Year
Do you smoke?	Yes No
Do you have a criminal record?	Yes No
If yes, please explain:

How would you rate your overall health?	Excellent Good Fair Poor
Do you have any physical disability which would prevent you from performing specific kinds of work?
	Yes No
If yes, please explain the work limitations:

What is your energy level?	Excellent Good Fair Poor
Are you now, or have you been treated for:
A drug or alcohol problem?	Yes No
An eating disorder?	Yes No
Do you have allergies?	Yes No
If yes, please explain:

Do you like pets?	Yes No
Are you willing to take care of pets?	Yes No
If no, please explain:

Do you have any physical or health limitations?
Please explain: I.E. Poor back (not able to lify more than 20 pounds such as an infant?)

Childcare / Elderly Care Experience:
Years of experience:
Tell us about your experience:
If happy, how long would you consider staying with a family?

Are you willing to travel with the family?
Is there any other information you would like to add that would be helpful in placing you with the right family?
Why do you want to be a caregiver?

What are your hobbies, interests?

What do you see as your personality strengths?

What do you see as your personality weaknesses?

Describe your personality?

Do you have experience with any type of special needs?
Please explain:

Preferred schedule:
What is your desired schedule?

Reference 1:
Name:
Home Phone:
Work Phone:
Relationship:
Reference 2:
Name:
Home Phone:
Work Phone:
Relationship:
Reference 3:
Name:
Home Phone:
Work Phone:
Relationship:

In the space below, write an essay that tells us about you, your family, and where you grew up. Also, tell us about your experiences with children. Please be as specific as possible.

Elderly Care / Disabled Care Competency Questions
Do you have experience caring for the elderly?

Do you have experience caring for the disabled?

Why do you want to work as a caregiver for the elderly/disabled in Canada?

What is your profession?

What was your last elderly / disabled job? Tell us what you did?

How would you describe your personality? How do you think your closest friends would describe you and your personality?

What do you like about caring for the elderly/disabled?

How do you feel about doing housework along with caring for the elderly/disabled?

What are your strong points in caring for the elderly/disabled?

Resume
Please attach your resume below or send your resume via email or by fax: