Application Forms - Covered Caregiver

Step 1...

http://beta.coveredcaregiver.com

Your Full Name:
Street Adress:
City: State: Zip:
Home Phone: Cell Phone: Tax ID: Do you Smoke? Yes No
Date of Birth	Ethnicity (Optional)
How did you hear about us? Craigslist Online Classified Penny Saver Acorn Church Senior Center CalJOBS Posting Board
Are you currently employed / provide Care to others? Yes No If Yes, Please explain.:

Most clients require transportation, often using the Care Provider’s vehicle:

Do you have dependable transportation?: Yes No		If Yes Make & Model:
License plate #	Driver license #	Auto insurance policy #
Insurance company	Insurance agent name	Insurance agent phone

Appx. hours per week available:	Days/Times you are available	Days & times not available	Can you be called at the last minute in case of emergency? Yes No
Select the areas that you will accept work Thousand Oaks/Newbury Park Westlake Village Ventura Oxnard Agoura Hills Camarillo Simi Valley Moorpark

High school	City/State	Dates
College	City/State	Dates
Other	City/State	Dates
Degrees/certificates – All Degrees / Certificates must be presented copy. All will be verified with provider/issuer.
Special skills or courses – Any skills that assist in making you qualified as a professional Care Provider.

Discuss any training or experience working with the elderly. How are you trained and/or experienced in working with the elderly?
What do YOU do that shows and proves you’re Reliable, Trustworthy and Honest?
What would you like least about working with the elderly?

Please indicate which of the following skills you are prepared to provide if referred to seniors / families

Please provide at least five years of recent, verifiable work history followed by verifiable references.