Care Specialist Application

Position you are applying for: select all areas of interest*

Child Care / Nanny - live-in
Child Care / Nanny - commuter
Tutor
Senior/Elderly Care
Housekeeping
Home/Office Organizer
Personal Assistant
Event Planner

Do you have experience in the area of work for which you are applying?*

Yes - I have ____ years of experience in the field
No - but I have academic background and/or certifications

PERSONAL INFORMATION

Name*

First Last

Birth Date:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone*

Provide an alternative phone number: ( ) ________________________________ Contact person: ____________________________________

Email*

Social Security or ITIN Number*

#_______________________________________

AVAILABILITY AND SPECIAL SKILLS

Available Starting Day:*

Hours available to work*

Days available to work:*

Do you have driver's license?*

Yes
No

List State and License Number*

Are you certified in First Aid?*

Yes
No

Are you certified in CPR?*

Yes
No

Do you swim ?*

Yes - but don't go in deep waters
Yes - very confortable in deep waters
No

Do you have lifesaver certification?*

Yes
No

Are you willing to become certified in these areas?*

Yes
NO

Do you have cooking skills?*

Yes - I have cooked for large groups and/or have catering experience
Yes - but I only cook for my household
No

BACKGROUND INFORMATION

Have you ever had a moving or driving related violation or traffic accident (including tickets)*

Yes
No

If yes, list specifics:

Have you ever been arrested or convicted of a felony and/or a misdemeanor?*

Yes
No

If yes, please explain

Have you ever been the subject of a substantiated complaint of child or sexual abuse?*

Yes
No

If yes, explain

FOR LIVE-IN APPLICANTS ONLY

The next question is for live-in applicants only

Have you ever lived away from home before?

Yes
No

If yes, for how long, and where?

MEDICAL - please respond to all questions*

Have you done a recent physical exam?*

Yes
No

If yes, when?

Please list any medical conditions you have:*

Do you have all inmunizations up do date?*

Yes
No

Do you have any diet restrictions?*

Yes
No

If yes, explain

Do you take any medication for anxiety or depresion?*

Yes
No

Have you ever been recommended to an alcohol or substance rehabilitation or mental health treatment?*

Yes
No

If yes, when and where?

List your allergies, if applicable

List any pets you would NOT be comfortable being around:

EDUCATIONAL BACKGROUND - Mark the highest educational level completed*

High School or GED
Certificate Program - specify the type of program
Some college credits - specify the area
Associates Degree - specify the area
Bachelor's Degree - specify the area
Other - specify

Please add any other type of certifications, special training and/or coursework related to the child care, home care, cooking and/or landscaping industry

Please specify the type of certificate / vocational education / college credits or degree you have.Please upload your certificate of completion, diploma, or letters that confirm your credentials.

Please upload your resume and other certifications to assist us in the identification of suitable position referrals for you*

EMPLOYMENT HISTORY

List your last three employment experiences: (start with the most recent)*

Location: Position: Phone Number: Supervisor: Length of time you worked at this location: Reason for leaving:

List your next employment experience:*

Location: Position: Phone Number: Supervisor: Length of time you worked at this location: Reason for leaving:

List another experience*

Location: Position: Phone Number: Supervisor: Length of time you worked at this location: Reason for leaving:

Desired salary range:*

List 3 references with phone number and email*

Reference #1	Reference #2	Reference #3

Signature*

I certify that I have answered all the questions on this application accurately and to the best of my knowledge. I have not withheld any information which would cause the information given above to be misleading. I understand that any inaccurate or misleading information is grounds for termination of employment.

AVAILABILITY AND SPECIAL SKILLS

BACKGROUND INFORMATION

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