Caregiver Application

General Information

First and Last Name:

Email:

Mobile Number:

Home Number:

Best Number to Contact:

Street Address (including apt number):

City:

State:

Zip:

How Did You Hear About Us:

I am available to work:

Full-Time (more than 35 hours per week) Part-Time (less than 34 hours per week)

I am interested in the following type of work
(Please check all that apply):

Requested Pay Rate (can provide a range):

Geographic Preference:

Employment History or Volunteer Organization
(starting with most recent position)

Dates of employment/Volunteer Service:

Position:

Type of employment/Volunteer Service
(p/t, f/t, live-in, live-out, child care, elder care):

Description of duties:

Reason for leaving:

Employer 2

Dates of Employment/Volunteer Service:

Position:

Type of employment/Volunteer Service:

Description of duties:

Reason for leaving:

Employer 3

Dates of Employment/Volunteer Service:

Position:

Type of Employment/Volunteer Service:

Description of duties:

Reason for leaving:

Give a brief description of any additional experience related to this field:

Education Summary

List any applicable certifications or licenses:

Are you willing to take additional certification courses?

Yes No

Select your highest level of education:

High School Graduate University 1 Year University 2 Years University 3 Years University 4 Years University Graduate Post Graduate Studies

If you are a college graduate list your degree:

Please list any post graduate studies:

Provide any additional skills or qualifications such as tutoring, exercise instruction, pet training, bi-lingual ability, etc.

I certify that all information that I provided in this application is true, accurate, complete and correct. I authorize investigation of all information provided in this application. I authorize the parties and entities I listed in this document to provide all information they may have regarding me and my character. I authorize the disclosure of any information about me, including but not limited to information obtained from the parties and entities I listed in this document, to Crunch Care Inc. (“Crunch Care”), its affiliated entities and representatives, and clients and potential employers. I understand and agree that any misrepresentation, falsification or material omission of information on this application may be grounds for Crunch Care to refuse to refer or place me.

I understand and agree that Crunch Care does not unlawfully discriminate in referrals or placements, and that no question on this application is used for the purpose of limiting or excusing any applicant for consideration for referral, placement on any basis prohibited by applicable laws or regulations.  I further understand and agree that Crunch Care does not guarantee my referral, placement, or any terms of employment.

I release Crunch Care and its owners, agents, employees, officers, directors, attorneys, representatives, and clients, and all of their affiliated entities and representatives, from any and all liability as a result of soliciting, providing or receiving information regarding me or my character, or the use or disclosure of such information.

Thank you for taking the time to fill out the preliminary application. Upon submittal of this form you will be taken to the site home page. Thank you for your interest.

**Please print and retain a copy of this preliminary application for your records.**