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Local Elder Caregiver Application Form (Live-Out)
Nanny/Caregiver Contact Information
Full Name
*
Email
*
Phone Number
*
Current Address
*
Age
*
Date of Birth
*
Place of Birth
*
Marital Status
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?
What is your desired hourly wage?
How long are you willing to work for your future employer?
Please describe your current daily routine
Please describe your current daily routine
Are you willing to work a split shift?
Yes
No
Occasionally
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 month’s 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:
How would you rate your housecleaning ability?
Outstanding
Above average
Average
Below average
Are you willing to perform light housekeeping duties such as:
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
Email of Employer 1
Phone number of Employer 1
Address of Employer 1
Start Date of Employment
Left Date of Employment
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 children’s age(s) and gender, housekeeping duties, play activities, etc.):
Reason for leaving:
Canadian Employment Experience (2)
Name of Employer 2
Email of Employer 2
Phone number of Employer 2
Address of Employer 2
Start Date of Employment
Left Date of Employment
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 children’s age(s) and gender, housekeeping duties, play activities, etc.):
Reason for leaving:
International Employment Experience (if applicable)
Name of Employer
Email of Employer
Phone number of Employer
Address of Employer
Start Date of Employment
Left Date of Employment
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 children’s age(s) and gender, housekeeping duties, play activities, 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:
Supply factual, truthful, and complete required information to Preferred Personnel
Provide references and contact information of current/past employers for employment authentication
Be confidential about employers and families personal information
Be available by phone or email to Preferred Personnel and potential employers. No contact results in no employment
Be punctual for interviews with employers
Be courteous and cancel an interview with potential employers with sufficient notice by directly contacting the employer by telephone
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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