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702 N Carrollton Ave
New Orleans, LA

(504) 486-5044
help@dependablecare.net

Mon - Fri 8:30-4:30
24/7 Referral Coordinators Available

Adult Caregiver Application

This checklist consists of the minimum requirements for registry accreditation in our industry. Your documentation and licensing must always be kept current.

All documentation listed below must be current and in our office prior to our granting you an interview and/or orientation. You may hand deliver, email or postal mail your completed application and required documents.

You may complete this online below, or download this form as a printable PDF.

Name: Last First M.I.
Business Name (if applicable)
Home Mailing Address: Apt.: D.O.B.:
Office Mailing Address: Apt.: D.O.B.:
City: State: Zip: How Long:
Business Ph:
Cell Ph: Other Ph:
(If you have resided at a different address within the last 5 years, then please list the previous address below)
Attach additional sheets if necessary.
Previous Address:
City: State: Zip: Period of Time Lived There:
Previous Address:
City: State: Zip: Period of Time Lived There:
Previous Address:
City: State: Zip: Period of Time Lived There:
Date Available to Start Work for New Client: Referred by:
Email: Marital Status: Soc. Sec:
Name of Your Business: EIN:
Have you ever been referred by Dependable before? If yes, give dates:
Do you have any friends or relatives referred by Dependable? If yes, name:
Are you a smoker?  Yes No Do you have a vehicle?  Yes No Is the vehicle a:
Are you interested in being a child care provider? Yes No If so are you Child/Infant CPR Certified? Yes No
Will you work with cats on the premises? Yes No If no, why not:
Will you work with dogs on the premises? Yes No If no, why not:
Have you ever been convicted of a crime other than a minor traffic violation?  Yes No
If YES, please explain:
Have you worked under any other names (maiden name, nickname, etc.) that would help us check your work record?
What makes this particular type of work appealing to you?
Emergency Contact(s): (Name and Number)
Name: Number:
Please indicate the locations in which you are able to be referred: (Check all that apply)
 Abita Springs Chalmette Covington Kenner Lacombe Madisonville Hammond Mandeville Metairie New Orleans Slidell Westbank Laplace Picayune, MS Mississippi (certain areas)
Indicate the times you are seeking referrals on a regular basis: (Check all that apply)
Days:
 7a-3p 7a-5p 7a-7p
Evenings:
 3p-11p 7p-7a 4p-12a
 Rotating Weekends Holidays Any 4 Hours in the morning ANYTIME Other Times Available:
Preferences (Check all that apply)
Would you prefer:  Private Home Nursing Home Hospital Assisted Living Center
Have experience with:  Peg Tubes Catheters Hoyer Lifts Lifting Patients (with little/no asst.)
   Paralyzed Patients Psych Patients Alzheimer's Patients Dementia Hospice Care
   Parkinson's Colostomy Bag Diabetes Care Trach Tubes Placing Patients in Wheelchair
   Blood Pressure Monitoring (manual/digital) Contagious Diseases Oxygen Care
Would you perform:  Errands Empty bedside Commodes Escort to Appointments
   Bath Meal Preparation Light Housekeeping


Licenses & Certifications
License Number Date Received and/or Expiration Date
Certified Nurses Aide (CNA)
Licensed Practical Nurse (LPN)
Emergency Medical Technician (EMT)
Medical Technician Level I
Personal Care Attendant (PCA)
Registered Nurse (RN)


Education
Name of School Attended Course of Studies / Degree Did you Graduate?
High School  Yes No
Community College  Yes No
Technical Training School  Yes No
College  Yes No

Please list any additional information (including any special skills or equipment) that may be helpful to us in considering your registration application and in identifying potential client opportunities that match your preferences and professional background, for example, if you have experience with a Hoyer Lift.


Do you speak any languages other than English? If so, please indicate:  N/A SPANISH FRENCH OTHER


Work History

Please list your last 5 years of work history as related to caregiving or the medical field. Please begin with your current or most recent position.


Most Recent Work – All information must be complete

Employer/Client:

Dates of Employment/Contract:

From to

Contact Person:

Address:

Phone:

Hourly Earnings:

Starting Ending:

Job Title (if applicable):

Reason engagement ended:

Work Performed/Duties:

Second Most Recent Position

Employer:

Dates of Employment:

From to

Supervisor:

Address:

Phone:

Hourly Rate/Salary:

Starting Ending:

Job Title:

Reason for leaving:

Work Performed/Duties:

Third Most Recent Position

Employer:

Dates of Employment:

From to

Supervisor:

Address:

Phone:

Hourly Rate/Salary:

Starting Ending:

Job Title:

Reason for leaving:

Types of Services Performed:

Fourth Most Recent Position

Employer:

Dates of Employment:

From to

Supervisor:

Address:

Phone:

Hourly Rate/Salary:

Starting Ending:

Job Title:

Reason for leaving:

Types of Services Performed:

Please be sure you have listed your last 5 years of work history.

I certify that all information given herein is true and correct to the best of my knowledge. I authorize any investigation of all statements and information contained in this registration application for gaining access to client referrals which is necessary in arriving at a referral decision.

DNFC, Inc. reserves the right to refuse any applicant for registration.

Signature of Applicant: (Initials)