Apply - Chesapeake Caregivers

Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Have you ever been convicted of a felony *

Yes
No

Have you ever been investigated for abuse, neglect or domestic violence? (copy)

Yes
No

Are you avalable all hours

Yes
No

Do you have a valid driver's license?

Yes
No

Do you have your own vehicle?

Yes
No

Are you willing to transport clients in your private vehicle?

Yes
No

What is the maximum number miles you are willing to travel from your home to an assignment?

Are you willing to drive a client's vehicle?

Yes
No

Are you a smoker?

Yes
No

Live-Ins - Being a Live-In means several consecutive days of care where the Caregiver stays at the care recipient's home for the entire number of days. Are you interested in providing Live-In care?

Yes
No

Please define your availability

How did you hear about us?

Please list all work history in the past 5 years

Please check any of the following you are willing to work with

Please check all you have experience with

Please check all certifications you currently hold

Resume Upload

Click or drag a file to this area to upload.

Attach resume or work history here

Agree to terms of appication *

By submitting this form I agree to the statement below

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection of this application and or discharge at any time during employment. I authorize Chesapeake Caregivers to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law-enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law-enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment. I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent me from working with Chesapeake Caregivers. I understand that I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.