Golden Path Caregiver Application

Personal Information

First Name *

Last Name *

Email *

Phone Number *

Date of Birth *

Last 4 Digits of SSN *

Current Address *

City *

State *

Zip Code *

Employment Availability

Preferred Work Schedule *

Weekdays Weekends Evenings Overnight Flexible

Available Hours Per Week *

Desired Start Date *

Experience & Certifications

Years of Caregiving Experience *

Certifications & Training *

CPR/BLS First Aid CNA (Certified Nursing Assistant) HHA (Home Health Aide) Dementia Care Training Other

Types of Care Experience

Elderly Care Dementia/Alzheimer’s Mobility Assistance Personal Care Companion Care Post-Operative Care

Skills & Abilities

Core Competencies *

Patient Communication Bedside Manner Trustworthiness Reliability Problem Solving Attention to Detail

Languages Spoken

References

Professional References (Please provide at least 2)

Reference Name *

Relationship *

Phone Number *

Email *

Reference Name *

Relationship *

Phone Number *

Email *

Background & Background Check Authorization

Have you ever been convicted of a crime? *

No Yes

I authorize Golden Path Companion Care to conduct a background check including criminal history, driving record, and reference checks.

Personal Statement

Why do you want to work as a caregiver? *

What are your greatest strengths as a caregiver? *

Additional Information

Do you have reliable transportation? *

Additional Information

I certify that the information provided in this application is true and complete. I understand that any false information may result in immediate disqualification or termination.