Caregiver Profile Form
Complete this form to help us understand your qualifications and preferences
Contact Information
Name
*
Cell
*
Email
*
Address
*
City/Town
*
Zip Code
*
Current Employment Status
Currently Working
*
Yes
No
Seeking
*
Full-time
Part-time
Per Diem
Fill-in/Backup
Certifications & Credentials
Current and Active Certification (check all that apply)
RN
LPN
HHA
PCA
CNA
Other
License/Certification Expiration Date (if applicable)
Transportation
Do you drive
*
Yes
No
Do you have a current and valid driver's license
*
Yes
No
Do you have a car to use for work-related commuting and travel
*
Yes
No
Work Environment Preferences
Work with Pets
Yes
No
Depends on type/size
Work with Smoker
Yes
No
Prefer no but will consider
Experience & Skills
Years of Experience in Home Care
*
Select years of experience
Less than 1 year
1-3 years
3-5 years
5-10 years
10+ years
Experience Level with (check all that apply)
Dementia/Alzheimer's care
Parkinson's disease
Stroke recovery
Diabetes management
End-of-life/hospice care
Post-surgical care
Physical therapy assistance
Specialized Skills (check all that apply)
Hoyer lift operation
Catheter care
Feeding tube care
Wound care
Oxygen administration
Medication reminders
Transfer assistance
Meal preparation
Light housekeeping
Errands/grocery shopping
Availability & Preferences
Available Start Date
*
Immediate
Within 1 week
Within 2 weeks
Within 1 month
Flexible
Preferred Work Schedule (check all that apply)
Weekdays
Weekends
Days
Afternoons
Evenings
Overnight
Live-in
Preferred Case Type
Live-in only
Hourly shifts only
Either live-in or hourly
24-hour shifts
Overnight only
Maximum Commute Time
15 min
30 min
45 min
1 hour
1+ hours
Preferred Service Areas (cities/towns on Long Island)
Minimum Hours per Week Desired
Maximum Hours per Week Available
Client Preferences
Willing to Work with
Female clients only
Male clients only
Either gender
Professional Information
Has Required ID to Complete I-9 and W-4
Yes
No
Not Sure
Languages Spoken (check all that apply)
English
Spanish
Russian
French Creole
Mandarin
Italian
Other
Work Authorization & Compliance
Authorized to Work in US
*
Yes
No
Background Check
Willing to complete
Already have one
Professional References Available
Yes
Need to gather
Resume/CV
Available
Will provide
Additional Information
How did you hear about First Call?
Indeed
Online search
Referral
LongIsland.com
Facebook
Other
Desired Hourly Pay Range (Min)
Desired Hourly Pay Range (Max)
Any scheduling restrictions or additional information
Acknowledgments
I understand this is an inquiry form and not a guarantee of employment
I authorize First Call to share my information with senior care providers, home care agencies, and families seeking caregivers
Date
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