Safe At Home LLC
Caregiver Employment Application — please complete all fields to the best of your ability.
Full Name
Phone Number
Email Address
At least one contact method (phone or email) is required.
Date Available to Start
Current Address
Address Line 2
City
State
ZIP
Desired Position
How did you hear about us?
Please indicate your general availability.
Days Available
MonTueWedThuFriSatSun
Shift Availability (check all that apply)
Morning (7am–12pm) Afternoon (12pm–5pm) Evening (5pm–10pm) Overnight (10pm–7am)
Total hours available per week
Preferred number of hours/shifts per week
Available on short notice/emergencies?
YesNo
Available weekends?
Available holidays?
List your most recent three employers.
Employer #1 – Company Name
Supervisor Name & Phone
Position Title
Dates of Employment
Reason for Leaving
Employer #2 – Company Name
Employer #3 – Company Name
CPR Certified First Aid Dementia Care Training Transfer Assistance Experience with ADLs
Other relevant certifications or skills
Please provide two professional references.
Reference #1 – Name
Relationship
Reference #2 – Name
Are you comfortable working in homes with pets?
YesNoSomewhat
Are you comfortable working in homes with monitoring cameras?
YesNoWith Conditions
Do you have a reliable vehicle available for work-related travel?
YesNoSometimes
Vehicle Year, Make & Model
If no or sometimes, please explain
Do you have any physical or other limitations that would prevent you from performing caregiving duties?
NoYes
I certify that the information provided above is true and complete to the best of my knowledge.
Type Full Name as Signature
Date
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