Local Elder Caregiver Application Form (Live-In)

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Caregiver Contact Information

Your Name (required)

Your Email (required)

Your Phone Number (required)

Current Address (required)

Age (required)

Date of Birth (required)

Place of Birth (required)

Marital Status

Do you have any family at your desired location on employment?
 Yes No

LCP (live -in caregiver program, if applicable)

Arrival Date

Work Permit Expiry

Months Employed on Live-In Program (according to ROE)

Education

High School (Year Completed)

Post Secondary (Institution Name, Year Completed, Degree Obtained)

Childcare/Eldercare Training Courses

First Aid/CPR Certification Dates

Additional Education

Employee Information

Preferred location of Employment
 Edmonton St. Albert Sherwood Park Rural Calgary Other All

Date Available to start

How long are you willing to work for your future employer?

Will you live-out on your days off?
 Yes No

Please describe your current daily routine

Are you willing to work flex hours/days?
 Yes No Occasionally

Are you willing to work a split shift?
 Yes No Occasionally

Are you willing to be on call at night?
 Yes No

Are you willing to work in a smoking environment?
 Yes No

Would you be willing to go on vacation with your employer?
 Yes No

Do you have any experience with any of the following ailments?
 Alzheimer’s/Dementia Diabetes Blindness Heart Conditions Deafness Physical Disabilities Other

Are you capable of lifting from a bed or wheel chair?
 Yes No

Are you familiar with distributing medications?
 Yes No

Are you willing to assist with personal care such as bathing, walking, eating, etc. ?
 Yes No

Are you able to assist with social activities and errands?
 Yes No

Please describe companion activities you would do:

Do you like pets?
 Yes No

Have you experience caring for any pets?
 Yes No

If yes, what kind of pet(s)?: What did you do with this/these pet(s)? Please describe

Do you have allergies?
 Yes No

If yes, what are you allergic to?

Are you medically and physically fit to work?
 Yes No

If no, are there tasks you are unable to do?

Do you have a driver’s license?
 Yes No

If no, are you willing to learn to drive and take driver‘s training courses?
 Yes No

If yes, what kind of licence? (i.e. international, Alberta)

If yes, how many months or years of driving experience do you have?

If yes, have you ever been in an accident?
 Yes No

Domestic Experience

Are you able to take messages and provide instructions on the telephone in English?
 Yes No

Can you follow written instructions from an employer?
 Yes No

How would you rate your cooking abilities?
 Outstanding Above average Average Below average

Please describe what dishes you can make:

Are you able to follow instructions from a cookbook?
 Yes No

Do you enjoy baking?
 Yes No

How would you rate your housecleaning ability?
 Outstanding Above average Average Below average

Are you willing to perform light housekeeping duties such as: (hold ctrl to select more then one):

 Tidying Vacuuming Mopping Laundry Washing dishes cleaning bathrooms

Do you know how to iron and hand wash clothing?
 Yes No

Do you know how to mend (simple hems etc.)?
 Yes No

Have you experience with gardening/plant care?
 Yes No

Canadian Employment Experience

Name of Employer 1

Address:

Email of Employer 1

Phone number of Employer 1

Dates of Employment
Started: Left:

Will you use this employer as a reference?
 Yes No

Have you had problems with this employer?
 Yes No

If yes, please describe:

Detailed Job Description (Please list all tasks and duties that you completed in the home on a daily basis. Include client's age, aliments, housekeeping duties, personal care duties, etc):

Reason for leaving:

Canadian Employment Experience (2)

Name of Employer 2

Address:

Email of Employer 2

Phone number of Employer 2

Dates of Employment
Started: Left:

Will you use this employer as a reference?
 Yes No

Have you had problems with this employer?
 Yes No

If yes, please describe:

Detailed Job Description (Please list all tasks and duties that you completed in the home on a daily basis. Include client's age, aliments, housekeeping duties, personal care duties, etc):

Reason for leaving:

International Employment Experience (if applicable)

Name of Employer

Address of Employer

Phone Number of Employer

Email of Employer

Dates of Employment
Started: Left:

Will you use this employer as a reference?
 Yes No

Have you had problems with this employer?
 Yes No

If yes, please describe:

Detailed Job Description (Please list all tasks and duties that you completed in the home on a daily basis. Include client's age, aliments, housekeeping duties, personal care duties, etc):

Reason for leaving:

Personal Information

Do you need time off to attend religious services? If yes, when?:

What are your hobbies and interests?

What languages do you speak?

Do you smoke?
 Yes No

Do you drink?
 Yes No

Can you swim?
 Yes No

What activities do you enjoy?

What are your future goals?

What would you like potential employers to know about you? (This is your area to shine, to really give your future employers a window of whom you truly are. Please list information about

I hereby agree that I will:

  1. Supply factual, truthful, and complete required information to Preferred Personnel
  2. Provide references and contact information of current/past employers for employment authentication
  3. Be confidential about employers and families personal information
  4. Be available by phone or email to Preferred Personnel and potential employers. No contact results in no employment
  5. Be punctual for interviews with employers
  6. Be courteous and cancel an interview with potential employers with sufficient notice by directly contacting the employer by telephone
  7. Be in contact with Preferred within 24 hours of interview with an employer

I agree to Preferred Personnel’s Code of Ethics
 Agree

I agree to provide Preferred Personnel with personal information which will be shared with potential employers in order to assist me in finding employment.
 Agree

Preferred Personnel will on your behalf at no cost:

  • Find an appropriate and good employer for you.
  • Prepare and consult on changes for your work permit in Canada.
  • Assist with any concerns, or questions regarding employment or immigration.
  • Provide ongoing support.
  • Assist in any labour disputes.

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