Caregiver Application

Thank you for your interest in becoming part of the Seniors At Home team. Please fill out this form to apply for caregiver jobs.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Primary Phone*
Secondary Phone
- Yes, Seniors At Home can contact me
Have you worked for Seniors At Home/JFCS in the past?
- Yes
- No
What year?
Reason for Leaving
How did you hear about Seniors at Home?
- Friend/Family Member
- Newspaper
- Flyer
- Event
- Google Search
- BING Search
- Facebook
- MyCNAjobs.com
Referral or Source Name
Emergency Contact information:
List 2 individuals we can contact in case of emergencies
1st Emergency Contact Name*
1st Emergency Contact Relationship*
e.g., Spouse, Brother, Friend, etc.
1st Emergency Contact's Phone Number*
2nd Emergency Contact Name*
2nd Emergency Contact Relationship*
e.g., Spouse, Brother, Friend, etc.
2nd Emergency Contact's Phone Number*
Work Preferences
Which position you are most interested in:
- Live- In Attendant
- Hourly Attendant
How many days per week are you available to work?
- 1
- 2
- 3
- 4
- 5
How many hours per shift are you available?
- 2hrs
- 4hrs
- 8hrs
- 12hrs
- 24hrs/live-in
Indicate as best as you can, the days and shifts you are available to work:
- Monday - Day
- Monday - PM
- Monday - Nights
- Tuesday - Day
- Tuesday - PM
- Tuesday - Nights
- Wednesday - Day
- Wednesday - PM
- Wednesday - Nights
- Thursday - Day
- Thursday - PM
- Thursday - Nights
- Friday - Day
- Friday - PM
- Friday - Nights
- Saturday - Day
- Saturday - PM
- Saturday - Nights
- Sunday - Day
- Sunday - PM
- Sunday - Nights
Day (7am-3pm), PM (3pm- 11pm), and Nights (11pm- 7am)
Client Preferences
You prefer to work with?
- Male Clients Only
- Female Clients Only
- Both
You prefer to work with?
- Single clients only
- Multiple clients
Are you allergic to the following?
- Cats
- Dogs
- Fragrances
- Smoke/cigarettes
Other Allergies
Are you able to work in a “smoking” home?
- Yes
- No
Additional Information
Other languages spoken:
List other special skills or experiences that you have used or have come across in homecare?
For example: Sewing, beautician, barbering, gardening, cooking, singing, etc.
Driving and areas of work
Please select the areas where you are willing to work:
San Francisco Area
- San Francisco only
North Peninsula Area
- South SF
- Daly City
- Pacifica
- San Bruno
- Hillsborough
- Millbrae
- Burlingame
- San Mateo
- Foster City
- San Carlos
South Peninsula Area
- Redwood City
- Palo Alto
- Menlo Pk
- Sunnyvale
- Sta. Clara
- Mt. View
- San Jose
Marin/Sonoma
- Sausalito
- Mill Valley
- San Rafael
- Tiburon
- Novato
- Kentfield
- Ross
- Fairfax
- San Anselmo
- Corte Madera
- Larkspur
- Greenbrae
- Rohnert Park
- Petaluma
- Santa Rosa
- Sebastopol
- Sonoma
- Windsor
- Cotati
- Penngrove
- Oakmont
- Healdsburg
Do you drive?
- Yes
- No
Do you have a valid driver’s license?
- Yes
- No
License Number
Are you willing to drive a client in your car?
- Yes
- No
Are you willing to drive a client’s car?
- Yes
- No
Can you provide proof of car insurance?
- Yes
- No
Certifications
Provide copies of certifications during the hiring process.
Are you certified for CPR?
- Yes
- No
Do you have First Aid training?
- Yes
- No
Are you currently certified as a:
- CNA
- CHHA
- LVN
- RN
Training and Education
Training and Education
School Field of Study Certificate/Degree
Work Experience
Please list your most recent employers first
Employer (Client’s Name)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor's Name & Phone
Start Date
End Date
Position held
Schedule
How many patients did you care for in a shift?
Duties and Responsibilities:
Reason for leaving:
Request for Reference Information Completed
- Yes
- No
Work Experience 2
Employer (Client's Name)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor's Name & Phone
Start Date
End Date
Position held
Schedule
How many patients did you care for in a shift?
Duties and Responsibilities:
Reason for leaving
Request for Reference Information Completed
- Yes
- No
Work Experience 3
Employer (Client's Name)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor's Name & Phone
Start Date
End Date
Position Held
Schedule
How many patients did you care for in a shift?
Duties and responsibilities
Request for reference information completed
- Yes
- No
Name*
First Last
I certify that all information given on this application is true and correct. I also understand that the Jewish Family and Children’s Services may make an investigation of my work and personal history, and I authorize all persons, schools, companies, corporations and law enforcement agencies to supply any information concerning my background and release them from any liability and responsibility arising from their doing so. I understand that any misrepresentation or omission of information will be sufficient cause for dismissal.

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Jewish Family & Children’s Services
Adoption Connection
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Seniors At Home is a division of JFCS

Caregiver Application

Emergency Contact information:

Work Preferences

Client Preferences

Additional Information

Driving and areas of work

Certifications

Training and Education

Work Experience

Work Experience 2

Work Experience 3