Caregiver Application

Applicant Information:
First Name
Likes to be called
Middle Name
Last Name
Company title
Address 1
Address 2
Zip Code
Primary Phone
Secondary Phone
Office Location
Date Of Birth
Default Time Zone
0/1000 characters
Care Matching
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Maximal Assist:

*Patient performs less than 25% of the activity

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Moderate Assist:

*Patient performs at least 50% of the activity

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Minimal Assist:

*Patient performs at least 75% of the activity


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Contact Guard Assist:

*Patients who can usually perform the activity by have a significant likelihood of requiring physical assistance

*Clinician/Caregiver maintains contact with the patient to be able to provide assistance immediately

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Stand By Assist:

*Patients who can usually perform the activity without assist,  but not consistently

*Verbal cues, assistance in problem solving during a transfer, assistance if an emergency arises

*Clinician not necessarily in close proximity to the patient

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*Med Reminders




*Oral Care




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*Pet Care

*Light Housekeeping

*Meal Preparation

*Grocery Shopping

*Watering Plants


*Social Activities

Interests Matching
Education & Training:
Employment History:
Professional References:
Additional Information:

I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for employment. I also authorize you to request and receive such information. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added or interpreted at any time, at the company’s sole option and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself.