Please provide the following contact information:

First Name
Last Name
RN/LPN/SW/MSW/CNA/HHA/Companion
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
Mobile Phone
Other Phone
E-mail

Do you have verifiable, professional references? Yes No    

Do you have your own car?

Have you had a physical within the past 6 months?

Have you had a TB test?

Do you have all of of your original documents, license etc?

Can you legally work in the United States?

Have you worked with Alzheimer's/dementia/memory impaired patients?

Can you work days?

Can you work nights?

Can you work weekends?

Can you provide live-in care?

Can you provide temporary live-in relief?

Can you provide temporary live-in relief?

Please provide the name and telephone numbers of three (3) professional references.  Before any applicant can attend orientation, we must speak and verify a minimum of three (3) professional references.  These can not be personal references. 

   

By submitting this form electronically to ElderCare at Home you are hereby acknowledging that the facts contained in this registration application are true and complete to the best of your knowledge and you understand that, if registered, falsified statements on this application shall be grounds for immediate deactivation and removal from our referral list.  You authorize investigation of all statements contained herein and the references and employers listed above to give any and all information concerning your previous employment and any other pertinent information that they may have, personal or otherwise, including reasons for termination, and release those persons and companies from all liability for any damage that may result from the utilization of such information.

How did you hear about us?

ElderCare at Home worker?     Yellow Pages     Penny Saver     Web-site     School     Other