Please fill out the following
All info is kept confidential
Personal info
First Name:
Last Name:
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Number in case of emergency:
E-Mail:
Social security number:
Date of birth:
What type of position are you applying for (Check all that apply)?
 3-Day live-in: 4-Day live-in:

2-Day live-in: Hourly:

Referred by
Newspaper Ad (Specify paper):
Workforce Services:
Other (Specify):
Legal Record
Have you ever been convicted of a felony?
Yes: No:
Have you ever been convicted of a misdemeanor?
Yes: No:

If Yes to either, please provide details.
By clicking here, you authorize Sheridan Care, Inc. to complete your background check
Transportation
Do you drive?
 Yes: No:
Driver's License #:
Do you have your own vehicle?
 Yes: No:
Make and model of your vehicle:
Availability
How many hours would like to work per week?
Would you like a live-in situation (3 or 4 days per week)?
Yes: No:
Would you like graveyard hourly shifts?
Yes: No:
What times are you available to work?
May we call you at the last minute in case of an emergency need?
Yes: No:
Education
Degrees/Certificates:
Special Skills/Courses:
Experience
Please list any training or experience you have working with the elderly:
What would you like most about working with the elderly?
Skills
 Please indicate whether you have assisted with or performed the following tasks for seniors.
Companionship:
Yes: No:
Bathing/Dressing:
Yes: No:
Bathing/Full Assist:
Yes: No:
Grooming:
Yes: No:
Incontinence:
Yes: No:
Transfer Assist:
Yes: No:
If Yes:
 Min: Mod: Max:
Laundry:
Yes: No:
Alzheimer's Experience:
Yes: No:
Driving:
Yes: No:
Vacuuming:
Yes: No:
Dusting:
Yes: No:
Dementia Experience:
Yes: No:
Housekeeping:
Yes: No:
Incontinent/Full Assist:
Yes: No:
Bed Linen Changes:
Yes: No:
Grocery Shopping:
Yes: No:
Rate Cooking:
1 2 3 4 5
(1=poor, 5=excellent)
Medication Reminders:
Yes: No:
Lifting:
No Lifting: 25 lbs or less:
25-50 lbs: 50-75 lbs:
75+ lbs:
References
Please list at least 3 business references with names and phone numbers:
When are you available for an interview?