Join Our Team

If you enjoy to assisting seniors in remaining active and independent,
use the form below to inquire about becoming a caregiver with Acti-Kare!

Fields marked with * are required.

First Name: *

Last Name: *

Home Phone: *

Cell Phone:

Alternative Cell Phone:

Email Address: *

Mailing Address: *

Mailing Address 2:

City: *

State/Province: *

Zip: *

Franchise Code (if known):

Country: *

How Did You Hear About
Our Company?: *

Education/Background (indicate name of school/location and yrs completed)

High School:

College:

Degree(s):

Other areas of study:

Experience

Are you currently a certified nursing assistant?

Yes No

Are you currently a home health aide?

Yes No

Are you CPR certified?

Yes No

Are you First Aid certified?

Yes No

Are you currently employed as a care provider?

Yes No

Do you have any experience that will aid in the independence of our clients?

Yes No

If yes, please explain:

What areas?:

Please describe prior caregiver experience: *

Comments:

Resume: (Optional. Copy and paste your resume in text format.)

References

Professional References & Telephone Numbers:

  Name Telephone Years known
1
2
3

Personal References & Telephone Numbers:

  Name Telephone Years known
1
2
3

Official Background Information

Have you ever been convicted of any crime, whether a misdemeanor or felony? Yes No
If yes, when, where and what crime?
Will you submit to a drug and background test if necessary? Yes No
Do you agree to a background investigation including a criminal background investigation? Yes No
When was your last background check performed? Date and by whom?

What area(s) are you comfortable assisting with in? (Check all that apply)

Companionship: Playing games / conversation Reading Escorting to appointments Other
Homemaker: Laundry Meal Preparation Housekeeping Pet Care
Writing & Reading Correspondence Shopping / Errands
Other Household Activities
Personal Care - Area of Specialization:
  Bathing Grooming Ambulation/Transfer Feeding

Availability/Schedule

Select up to three start/end intervals for each day of the week for which you are available. For example, you can select both Monday Start 9am -> End 10am, and Monday Start 3pm -> End 5pm, if you are free for both time periods.

Monday

Period 1 
Period 2
Period 3

Tuesday

Period 1 
Period 2
Period 3

Wednesday

Period 1 
Period 2
Period 3

Thursday

Period 1 
Period 2
Period 3

Friday

Period 1 
Period 2
Period 3

Saturday

Period 1 
Period 2
Period 3

Sunday

Period 1 
Period 2
Period 3

How many hours per week you are willing to work:

 

I certify that the information I have provided above is true, accurate and correct:*
Signature:   Date:

Please type name and date above.