Caregiver Application Form

Personal Information
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Educational Background  New Educational Background

Minimum one certificate is mandatory to be filled.

Certifications

Employment History  New Employment History

Please provide your latest employer information below.

Completion of a minimum of one skill/preference is required.

Skills/ Preferences

Skill Type

References   New Reference

Miscellaneous Questions

Q.) What is your availability to work? (6am-2pm, 2-10pm, or 10pm-6am shifts)
Q.) Are you legally authorized to work in the United States of America?
Q.) Do you have any specialized training? (ex: Hospice, Dementia, Alzheimers, Parkinsons)
Q.) If you have a valid California HCA Registry #, what is it? (This ID number begins with a "7" or a "4")
Q.) Does Therapeutic Home Care have your permission to verify your professional and personal references listed on this application?
Q.) Are you 18 years of age or above?
Q.) Please list at least one supervisor reference and two character references. Please list their full name, phone number, and relationship.
Q.) Please list your emergency contact, name, and phone number

* Caregiver Signature

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