Apply for CAREGiver - Home Instead 618

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Apply for CAREGiver

Hello and thank you for your interest in Home Instead. Please fill out the application below and click the Submit button when finished. Fields with an asterisk (*) are required.

Please note that this is the job board for the franchise office located at 28110 Avenue Stanford, Unit A, Santa Clarita, CA 91355. Each Home Instead franchise is independently owned and operated. To find a franchise near you, please visit the Careers page.

For job related questions please call the franchise office at 661-254-8701.

Summary
Title:	CAREGiver
ID:	1001
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Application Information
Notes:
Attachments
Resume:	Supported formats: Word, PDF, RTF, Text, and HTML.

	- or Upload from:


Cover Letter:	You can type in a Cover Letter or Copy/Paste from an existing document.

Additional Information

* How did you hear about Home Instead?

If applicable, please specify:

US CAREGiver Employment Application

APPLICANT NOTE

Peregrine Care, LLC is an independently owned and operated Home Instead® franchise located at 28110 Avenue Stanford, Unit A, Santa Clarita, CA 91355 661-254-8701. HCO #: 194700208 California License

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please call the franchise office at 661-254-8701.

Please read "Applicant Note" below.
Complete all parts of this application.
Application will be valid for 60 days.

This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead franchise. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body is required prior to employment.

PERSONAL INFORMATION

Other Names Previously Used:

	Last Name	First Name	Middle Name
1.
2.

Emergency Contacts:

	Name	Phone	Relationship
1.
2.

* Have you ever been employed here before?

Yes No

If yes, when?

* Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Yes No

AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

* What date are you available to begin work?

Please Complete all Areas of Availability.

* Total hours preferred to work per week:

* How many miles from home are you willing to travel?

* Do you have allergies?

Yes No

If yes, what are they?

* Are you willing to work with men, women, or both?

Men Women Both

* Do you have access to reliable transportation?

Yes No

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

Day	From	To
Monday	*	*
Tuesday	*	*
Wednesday	*	*
Thursday	*	*
Friday	*	*
Saturday	*	*
Sunday	*	*

CAREGIVING EXPERIENCE

Please indicate those tasks in which you have experience. For the areas that you do not have experience, please note if you are willing to learn.

Tasks	Experience Yes/No
Companionship/Conversation	* Yes No	Willing to Learn
Meal Preparation (meals/snacks)	* Yes No	Willing to Learn
Housekeeping (dust, vacuum, laundry)	* Yes No	Willing to Learn
Bathing/showering Assistance	* Yes No	Willing to Learn
Dressing Assistance	* Yes No	Willing to Learn
Showering Assistance	* Yes No	Willing to Learn
Medication Reminders	* Yes No	Willing to Learn
Hospice Care	* Yes No	Willing to Learn
Stroke Care	* Yes No	Willing to Learn
Dementia Care	* Yes No	Willing to Learn
Incidental Transportation & Errands	* Yes No	Willing to Learn
Incontinence Care	* Yes No	Willing to Learn
Personal Care Assistance (Female)	* Yes No	Willing to Learn
Personal Care Assistance (Male)	* Yes No	Willing to Learn
Alzheimer’s or Dementia Care	* Yes No	Willing to Learn
Diabetes Care	* Yes No	Willing to Learn
Hearing Impairment	* Yes No	Willing to Learn
Transferring Assistance (Example: helping a person from chair to standing position)	* Yes No	Willing to Learn
Ambulation Assistance (Example: Ensure a person’s stability and safety when moving)	* Yes No	Willing to Learn
Mechanical Lift (Hoyer Lift)	* Yes No	Willing to Learn

* How many year’s experience do you have as a Caregiver?

EDUCATION

	Name	City, State	Major Subjects or Certifications	Graduate?
Vocational/Technical				Yes No
College/University				Yes No

WORK HISTORY

MOST RECENT EMPLOYER

* Are you currently working for this employer?

Yes No

* May we contact?

Yes No

* Company Name:

* City:

* State:

* Company Phone:

* Dates Employed - From:

* Dates Employed - To:

* Job Title:

* Supervisor's Name:

* Duties:

Reason for Leaving:

SECOND MOST RECENT EMPLOYER

Are you currently working for this employer?

Yes No

If yes, may we contact?

Yes No

Company Name:

City:

State:

Company Phone:

Dates Employed - From:

Dates Employed - To:

Job Title:

Supervisor's Name:

Duties:

Reason for Leaving:

THIRD MOST RECENT EMPLOYER

Are you currently working for this employer?

Yes No

If yes, may we contact?

Yes No

Company Name:

City:

State:

Company Phone:

Dates Employed - From:

Dates Employed - To:

Job Title:

Supervisor's Name:

Duties:

Reason for Leaving:

BACKGROUND

List locations of residence for the past 7 years:

County:

State:

County:

State:

County:

State:

County:

State:

* Are you 21 years of age or older with a valid driver’s license?

Yes No

REFERENCES

If you are considered for a position, we may contact your references and would ask that you notify them in advance. Please do not list relatives or family/relations.

Professional References

Full Name	Phone Number	Best Time of Day to Call	Email	Relationship	Number of Years Known
*	*	* AM PM	*	*	*
*	*	* AM PM	*	*	*

Personal References

Full Name	Phone Number	Best Time of Day to Call	Email	Relationship	Number of Years Known
*	*	* AM PM	*	*	*
*	*	* AM PM	*	*	*

CERTIFICATION AND RELEASE

I certify that I have read and understand the applicant note 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 understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to pre-employment drug testing to detect the use of illegal drugs.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT FOR EMPLOYMENT

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date:

Submit

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