Application

In-Home Dementia & Alzheimer’s Care Specialist Application

Personal Information

Full Name

Phone Number

Email Address

City / State / Zip

Preferred Method of Contact

Phone

Position Availability

Which shifts are you applying for?

Day Shift

Overnight Shift

Both

Days available

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Preferred shift length

8 Hours

10 Hours

12 Hours

Flexible

Other

Earliest start date

Do you have reliable transportation to client homes?

Yes

Do you have a valid driver’s license?

Yes

Work Eligibility

Are you legally authorized to work in the United States?

Yes

Have you ever been convicted of a crime that would affect your ability to work with vulnerable adults?

Yes

If yes, please explain

Willing to undergo background check?

Yes

Willing to undergo drug screening?

Yes

Willing to undergo reference checks?

Yes

Experience & Qualifications

Years of caregiving experience

Less than 1 year

1 to 2 years

3 to 5 years

5+ years

Other

Years of geriatric care experience

Less than 1 year

1 to 2 years

3 to 5 years

5+ years

Experience with

Alzheimer’s CareDementia CareHospice CareMobility AssistanceTransfersOvernight CareBehavioral RedirectionMedication Reminders

Certifications held

CNAHHACPR/First AidDementia CertificationHospice TrainingOther

Certification expiration dates

Employment History

Employer 1

May we contact this employer?

Yes

Professional References

Caregiving Approach

What do you believe is the most important part of caring for elderly clients?

What experience do you have working with memory care clients?

What qualities make you a dependable caregiver?

Physical Requirements

Able to stand for extended periods?

Yes

Able to assist with transfers and mobility?

Yes

Able to lift up to 25 to 50 lbs if needed?

Yes

Able to lift up to 75 to 150 lbs if needed?

Yes

Applicant Statement

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading information may result in disqualification or termination.

Applicant Signature

Date

Cancel and return to Careers

Elin Rose
Home Care Assistance

Compassionate, purpose-driven care for your loved ones — every single day.

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Dallas – Fort Worth, TX

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