Caregiver Application Form

Personal Information
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Educational Background  New Educational Background

Certifications

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Employment History  New Employment History

Please provide your latest employer information below.

Completion of a minimum of one skill/preference is required.

Skills/ Preferences

Availability
Cooking Needs/Skills
Diagnoses/Experience
General
Language
Pets
Vehicle Type

References   New Reference

Miscellaneous Questions

Q.) Do you give Extended Circle Senior Services permission to text you?
Q.) Are you legally authorized to work in the United States?
Q.) Do you have a valid New York State Driver’s License?
Q.) Do you have reliable transportation?
Q.) How did you hear about this position?
Q.) Desired Start Date:
Q.) Are you available to work:
Q.) Are you available for (select all that apply)
Q.) Are you willing to travel within Western NY?
Q.) Background Check Authorization: I understand that a criminal background check, reference checks, a drug screen and driving record will be conducted as part of the hiring process. I certify that the information provided is true and complete and by selecting yes below and signing the application I am authorizing a background check, drug screen, reference checks and motor vehicle check be completed.

* Caregiver Signature

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