Family Care Options

Adult Caregiver Application

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Welcome to Family Care Options!

We are excited that you are interested in becoming a part of our company. Being a part of Family Care Options, you will have the opportunity to make a positive impact on the lives of families in need of assistance. If you are an expert in your field, dedicated and passionate about the service industry, we would love to have you join our team.

To apply, please fill out the application below.

We look forward to reviewing your application and welcoming you to the Family Care Options family.

Adult Caregiver Application

Family Care Options Adult Caregiver Application

The following is required upon registration: Please complete and sign application, (the application must be completely filled out completely).

Personal Information

First Name

Last Name

Phone *

Email *

Address

City

State

Postal code

What is your date of birth?

Where were you born?

Are you a US Citizen?

Yes

No

Do You use another name?

Yes

No

Driver License Number

Driver License State

Upload Drivers License/ Picutre ID

Upload Drivers License/ Picutre ID

What days are you available for work?

Mon
Tue
Wed
Thu
Fri
Sat
Sun
No elements found. Consider changing the search query.
List is empty.

Are you CPR trained?

Yes

No

Are You Certified in Nursing?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

Can you travel with the family?

Yes

No

Can you travel internationally?

Yes

No

Are you allergic to animals?

Yes

No

Are you comfortable around dogs or cats in the house?

Yes

No

Do you drive?

Yes

No

Do you have a car?

Yes

No

Have you had an accident/moving violation in which you were a driver in the last 3 years?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

If You had an accident/moving violation, Please explain.

Can you drive a stick?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

Can you use your car for work?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

Are you willing to relocate?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

If willing to relocate, when?

Do you have any relocation limitations or desires?

Do you smoke?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

If you smoke, how often?

Are you currently taking any medication?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

Please explain the reason you are on medication.

Was medication prescribed by a physician?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

Do you drink alcoholic beverages?

Select option

Yes
No
No elements found. Consider changing the search query.
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How often do you drink?

Do you have any dietary restrictions: Religious or other?

On a scale of 1-10, please rate your energy level

Do you have any allergies?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

If you have allergies, please explain.

Do you feel you are physically capable to do the job you are applying for?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

Do you have experience working with elderly people?

Yes
No
No elements found. Consider changing the search query.
List is empty.

If you have elderly care experience, where did you work?

How many years of experience do you have?

What were your job duties?

Were you in charge of your daily schedule?

Yes

No

Do you swim?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

How well do you swim?

Can you ride a bike?

Select option

Yes
No
No elements found. Consider changing the search query.
List is empty.

Will you ride a bike if asked to?

Yes
No
No elements found. Consider changing the search query.
List is empty.

Did you do any lifting?

Yes

No

Did you bath the adult?

Yes

No

Did you do laundry for the adult?

Yes

No

Did you cook for the adult?

Yes

No

Please explain your cooking for the adult.

Did you dress the adult you were caring for?

Yes

No

Can you change dressing from an open wound?

Yes

No

Did you give medicine reminders?

Yes

No

Did you drive the adult to doctors offices?

Yes

No

Education

What is your highest level of education completed?

Did you attend College, if yes, what college?

Do you have any special training or certifications?

Upload Your Resume, Diploma or Certifications

Upload Your Resume, Diploma or Certifications (PDF only)

By signing this application, I do hereby agree all facts contained herein are true to the best of my knowledge. By signing, I understand and agree that Family Care Options will order a background investigation from a third-party company and will include criminal, social security, and DMV check. I have the right and option to conduct my own background check and present it to Family Care Options upon registration. Any and all changes after completing this application must be done in person and approved by a Family Care representative.

Please sign your application here

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1(212) 748-8377

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New York, N.Y. 10019

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