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Caregiver Job Application Form Template

Streamline Your Caregiver Hiring Process with This Template

Finding the right caregiver can be challenging, particularly when your loved ones require dedicated support. This caregiver job application form template is designed to help you effortlessly attract and evaluate potential candidates, ensuring quality care for those who need it most. With its straightforward format, you'll benefit from a quicker hiring process, customizable questions to suit your specific needs, and easy data management for all applicants. Plus, it's tailored to be WCAG-aligned, ensuring accessibility for everyone involved. Try using the live template today and simplify your caregiver recruitment.

Full name (as it appears on your ID)
Email address
Mobile phone number
Current city and state
Are you at least 18 years old?
Yes
No
Are you legally authorized to work in the country where this job is located?
Yes
No
What type of caregiver role are you seeking?
Full-time
Part-time
Live-in
Temporary/On-call
Overnight only
Any
Which days are you available to work?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Flexible/varies
Which shifts can you work?
Early mornings (5am-9am)
Daytime (9am-5pm)
Evenings (5pm-10pm)
Overnights (10pm-7am)
Weekends
Holidays
Earliest date you can start
Desired hourly rate (enter a number or range)
How far are you willing to travel for a shift?
Up to 5 miles
Up to 10 miles
Up to 20 miles
Up to 30 miles
30+ miles
Live-in/On-site only
How many years of paid or unpaid caregiving experience do you have?
Less than 1 year
1-2 years
3-5 years
6-9 years
10+ years
Which tasks are you comfortable performing?
Which client needs do you have experience with?
Current certifications or licenses
CNA
HHA
PCA
LPN/LVN
RN
CPR/First Aid
Medication aide
None
Other
Please Specify:
Other certifications or licenses (optional)
Do you have a valid driver's license?
Yes
No
Do you have access to a reliable vehicle?
Yes
No
Are you comfortable working in homes with pets?
Yes
No
Depends on the pet
Prefer not to say
Have you completed a TB test or screening in the past 12 months?
Yes
No
What is your COVID-19 vaccination status?
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
Most recent employer or client
Position title
Start date
End date
Briefly describe your key duties and accomplishments
May we contact this employer or client?
Yes
No
Professional reference full name
Relationship to you
Reference phone
Reference email
Gender identity (optional)
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Age group (optional)
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Veteran status (optional)
I am not a veteran
I am a veteran
Prefer not to say
I certify that the information provided is true and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I authorize the company to verify information provided, including contacting references, consistent with applicable laws.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Type your full legal name as your signature
Signature date
I consent to be contacted via phone, SMS, or email about this application.
Yes
No
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Paper art illustration featuring a caregiver job application form with pen and clipboard, highlighting application details and design.

When to use this form

Use this caregiver application form when you need to screen in-home aides, companions, or CNAs quickly and fairly. It fits home care agencies, assisted living teams, and staffing services hiring part-time, overnight, live-in, or weekend relief. Ask about certifications, years of experience, comfort with dementia care and transfers, driver status, languages, and availability. The result: you shortlist qualified candidates, match them to cases faster, and reduce back-and-forth before interviews. If you also post open roles beyond caregiving, add an Apply for a position form to capture general interest. When you want resumes up front, pair this template with a Resume collection form so applicants can upload documents without email attachments.

Must Ask Caregiver Job Application Questions

  1. What certifications do you currently hold (CNA, HHA, CPR/First Aid), and what are the license numbers and expiration dates?

    This verifies training and compliance before you schedule interviews. Expiration details help you avoid lapses that can delay case starts.

  2. Which care tasks are you experienced with (dementia support, bathing, transfers, medication reminders, meal prep), and how many years in each?

    Specific skills help you place caregivers safely and match client needs. Years in each area also inform pay rates and supervision.

  3. What shifts can you work (days, evenings, overnights, weekends), and are you open to live-in or last-minute fill-ins?

    Clear availability reduces scheduling gaps and urgent call-offs. It lets you build reliable coverage across cases.

  4. Do you have a valid drivers license, reliable vehicle, and insurance to transport clients when needed?

    Many cases require errands or medical appointments, so transport readiness matters. This confirms eligibility and reduces risk for your agency and clients.

  5. Do you consent to a background check and can you provide two professional references with contact details?

    This safeguards vulnerable clients and may be required by law or payers. You can collect standard personal details alongside this using an Easy job application form.

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