Live-in Caregiver Companion Application

*Important*

We email your profile directly to the family looking to contract with someone. For your own benefit PLEASE use capital letters (ex: I, not i, or Jane, not jane). It may make the difference between you being seriously considered or not.

Thanks in advance, and good luck!

Office Notes

Code

Not required

Date *

Month Day Year

Full Name *

First Name Middle Name Last Name

E-mail *

Cell *

Home Phone

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

I would consider other live-in care positions that are..

within 2 hours drive of my home within 4 hours drive of my home almost anywhere in the US

Gender *

Female Male

Language(s) Spoken *

Professional Training. Check all that apply. *

None Certified Home Health Aide Certified Nursing Assistant CPR Hospital / Care Facility Trained Dementia / Alzheimer Caregiver Training

State(s) where you passed your certification test (CNA or CHHA)

PA, FL etc..

Check all the below that you have hands-on caregiving experience with: *

Dementia / Alzheimers Stroke Diabetes Parkinson's Colostomy Hoyer or patient lifts

All of our client's pay their live-ins through a household employee payroll service with your taxes deducted. What is your minimum daily rate for a live-in job?

Example: $200

Have Driver's License *

Yes No

Have Own Vehicle

Yes No

How many years of experience do you have performing ADL care on seniors? *

# of Years

Have worked as an (1099) Independent Contractor

Yes No Not Sure

What is the longest time period that you have worked with the same client, in months and/or Years? *

How would you describe yourself to a family thinking of contracting with you to be their live-in caregiver? *

How are you around pets? *

Cats okay Dogs okay Neither is okay

Are you okay working in a house where someone smokes inside the home? *

Yes No

Do you smoke tobacco? *

Yes No Yes, but never while in the clients home

Please list two live-in job references that we can contact to ask about your caregiving performance. These two references must be from previous families that have used your paid caregiving services.

*Please do NOT include references from your personal friends, co-workers, family or relatives, even if you worked for them in a caregiver capacity. Nothing will disqualify you faster than a fake reference with a friend.

Name of Reference 1 *

First Name Last Name

Reference 1 Phone Number *

Relationship to care recipient *

If "Other" please explain

Position began: *

Month Day Year

Position ended: *

Month Day Year

City and State of position

Ex: Miami, Florida

Care recipient's first name and age *

First Name Age

Service Performed *

Live-in Live-out

Give a DETAILED description of the job and the services that you performed. *

Reference Check

Name of Reference 2 *

First Name Last Name

Reference 2 Phone Number *

Relationship to care recipient *

If "Other" please explain

Care recipient's first name and age *

First Name Age

Position began: *

Month Day Year

Position ended: *

Month Day Year

City and State of position *

Service Performed *

Live-in Live-out

Give a DETAILED description of the job and the services that you performed. *

Reference Check

Can interview via video chat using:

Facetime Skype Neither

Upload resume (optional)

Upload Photo / Selfie (optional)

Smile :)

Digital Signature *

First Name Last Name

Grandma Joan acts solely as a recruiting, screening and referral source and does not employ or co-employ any live-in. The family is the employer, not Grandma Joan.

When complete, press the submit button below. We will contact you if we have any questions. Please do not call to see if we have any other openings.

Live-in Caregiver Application