Live-in Caregiver Companion Application

Live-in Caregiver 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*

MonthDayYear
Full Name*

First NameMiddle NameLast Name
E-mail*
Cell*
Home Phone
Address*

Street Address

Street Address Line 2

CityState

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

within 2 hours drive of my homewithin 4 hours drive of my homealmost anywhere in the US
Gender*

FemaleMale
Language(s) Spoken*
Professional Training. Check all that apply.*

NoneCertified Home Health AideCertified Nursing AssistantCPRHospital / Care Facility TrainedDementia / Alzheimer Caregiver TrainingOther
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 / AlzheimersStrokeDiabetesParkinson'sColostomyHoyer 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*

YesNo
Have Own Vehicle

YesNo
How many years of experience do you have performing ADL care on seniors?*
# of Years
Have worked as an (1099) Independent Contractor

YesNoNot 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 okayDogs okayNeither is okay
Are you okay working in a house where someone smokes inside the home?*

YesNo
Do you smoke tobacco?*

YesNoYes, 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 NameLast Name
Reference 1 Phone Number*
Relationship to care recipient*
If "Other" please explain
Position began:*

MonthDayYear
Position ended:*

MonthDayYear
City and State of position
Ex: Miami, Florida
Care recipient's first name and age*

First NameAge
Service Performed*

Live-inLive-out
Give a DETAILED description of the job and the services that you performed.*
Reference Check
Name of Reference 2*

First NameLast Name
Reference 2 Phone Number*
Relationship to care recipient*
If "Other" please explain
Care recipient's first name and age*

First NameAge
Position began:*

MonthDayYear
Position ended:*

MonthDayYear
City and State of position*
Service Performed*

Live-inLive-out
Give a DETAILED description of the job and the services that you performed.*
Reference Check
Can interview via video chat using:

ZoomWhatsAppFacetime (iphone)None
Upload Photo / Selfie

Upload a File
Smile :) Cancelof
Upload resume (optional)

Upload a File

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Digital Signature*

First NameLast 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.
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Live-in Caregiver Application