Form - Home Care Assistance oF Jefferson County

Thank you for your interest in working for our agency.
Please submit the application below to be considered for a position as a caregiver.

Applicant Information:

First Name

State

Middle Name

Postal Code

No middle Name

Home Phone

Last Name

Mobile Phone

Address

Email

Address Line 2

Location

City

Hours wanted weekly

Date Of Birth

Match Criteria

Please select checkboxes that match your skills and preferences.

General

Dementia Experience

OK with Client Smoking

Other/Misc:

Hospice Experience

Transfers

Evergreen/Bailey/Conifer

Incontinence Experience

Gait Belt Experience

Insured Automobile

Foothills-North side

Hoyer Lift Experience

Foothills-South side

Live-In Shifts OK

Pets

Lakewood

OK with Cats

OK with Dogs

Max client weight for transfers:

Education & Training:

High School

College

School

Degree received

Employment History:

Please provide your most recent positions of employment.

Employer

Supervisor

Phone Number

Address 1

Address 2

City

State

Postal Code

Date Employed

To

Employer:

Supervisor

Phone Number

Address 1

Address 2

City

State

Postal Code

Date Employed

To

Professional References:

Please provide professional references.

Name

Phone Number

Name

Phone Number

Name

Phone Number

Additional Information:

Have you ever been convicted of a felony?

What is your availability? Can you work weekdays, weekends,live-in schedule? Do you have any hourly restrictions?

What are your long-term dreams and aspirations? Please include both personal and professional goals.

Do you have reliable transportation?

What does "meaningful companionship" mean to you?

How have your educational experiences prepared you to be a caregiver?

I am responsible and reliable because?

How did you hear about us? For example: Indeed.com or a person's name:

Chat with us

👋

Hi! I'm your AI assistant. How can I help you today?

one-stop shop for all health home care needs

Welcome to our Home Care Services website! My name is Darlene Ashley, and I offer reliable and professional notary services for all your health and senior paperwork needs. Whether you’re preparing advanced directives, drafting a will, or managing other important legal documents, I’m here to help. I understand the importance of having these essential documents in place, and I’m dedicated to making the process simple, efficient, and stress-free. I would like you to please count on me for assistance anytime with your health care or senior-related paperwork, ensuring everything is legally sound and completed to your satisfaction. Let me provide the support you need during these important moments.

Thank You!