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Home Care Aide Registration Form Template

Streamline Your Home Care Aide Registration Process

If you're struggling to efficiently register home care aides, this template is designed just for you. It simplifies the process of collecting essential information, ensuring you meet regulatory requirements while streamlining your onboarding. With clear sections for personal details, qualifications, and emergency contacts, this form enhances your workflow, promotes compliance, and fosters faster hiring decisions. Plus, it's designed to be user-friendly and accessible, including WCAG-aligned labels for optimal inclusivity. Start using the live template to simplify your registration process today!

Use this Template (FREE) Live Preview
Full legal name
Email address
Mobile phone number
Address (street, city, state, ZIP)
Preferred contact method
Phone call
Text message
Email
Any
Are you at least 18 years old?
Yes
No
Languages spoken (include proficiency)
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Are you legally authorized to work in the country?
Yes
No
Do you have a valid government-issued photo ID?
Yes
No
Are you willing to undergo a background check?
Yes
No
Do you have a valid driver's license?
Yes
No
Do you have reliable transportation?
Yes
No
Current certifications and clearances (select all that apply)
Home Health Aide (HHA)
Certified Nursing Assistant (CNA)
CPR
First Aid
Medication Administration
TB test clearance
COVID-19 vaccination card
None of the above
Years of paid caregiving experience
No experience
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
Care settings you have worked in
Private home
Assisted living
Skilled nursing facility
Hospital
Hospice
Other
Please Specify:
Services you can provide
Are you comfortable with pets in the home?
Yes
No
Depends on the pet
Briefly describe your relevant experience or specialties
Maximum client weight you can safely transfer
Not applicable
Up to 100 lb
100-149 lb
150-199 lb
200+ lb
Earliest start date
Days you are available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred shift types
Mornings
Afternoons
Evenings
Overnights
Live-in
Weekends
On-call
Desired weekly hours
Up to 10 hours
10-20 hours
20-30 hours
30-40 hours
More than 40 hours
Are you willing to work holidays?
Yes
No
Service area (cities or ZIP codes you can cover)
Maximum commute distance
Up to 5 miles
Up to 10 miles
Up to 20 miles
Up to 30 miles
More than 30 miles
Professional reference name
Reference relationship
Reference phone
Reference email
May we contact your current employer?
Yes
No
Are you able to lift 50 pounds safely?
Yes
No
Not sure
Are you willing to follow infection control protocols (PPE, hand hygiene, testing as required)?
Yes
No
Do you consent to receive updates via text and email about opportunities?
Yes
No
Type your full legal name to sign
Today's date
I certify that the information provided is true and complete.
True
False
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Email address, Mobile phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing a home care aide registration form for FormCreatorAI article.

When to use this form

Use this registration form when you need to onboard new aides, build a compliant roster, or fill urgent shifts. It helps agency owners, staffing coordinators, and independent caregivers share credentials, availability, and work history in minutes. Use it after job fairs, during seasonal demand, or when a hospital discharge requires same-day coverage. The answers you collect let you verify qualifications, match skills to client needs, and schedule with confidence. If you also accept new client leads, pair it with the Home care inquiry form to capture service details. For higher-acuity clients, follow up with a Home health assessment form so you can assign the right aide the first time.

Must Ask Home Care Aide Registration Questions

  1. What is your full legal name and the best phone and email to reach you?

    This verifies identity and prevents mix-ups when matching applications, background checks, and timesheets. Clear contact info lets you confirm shifts fast and reduce no-shows.

  2. Which certifications, licenses, and state registration numbers do you hold?

    Listing credentials proves compliance and speeds verification with state registries. If you also need document uploads, route candidates to the Home health care application form to collect copies.

  3. Do you authorize a background check, and have you had any disqualifying convictions?

    This protects clients and keeps you aligned with state and payer rules. Early disclosure avoids delays and lets you make informed, consistent hiring decisions.

  4. What days, times, and service areas can you work?

    Scheduling is easier when you know exact availability and travel range. You can cover gaps, plan weekend rotations, and reduce last-minute scrambling.

  5. Which care tasks and specialties are you trained and comfortable performing?

    Detailing skills like transfers, dementia support, medication reminders, and activities of daily living helps you match aides to client needs. This improves outcomes, reduces turnover, and cuts training time.

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