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.

Emergency Contact(s): (Name and Number)
Name:		Number:

Indicate the times you are seeking referrals on a regular basis: (Check all that apply)
Days: 7a-3p7a-5p7a-7p	Evenings: 3p-11p7p-7a4p-12a	Rotating WeekendsHolidaysAny 4 Hours in the morningANYTIME	Other Times Available:

Preferences (Check all that apply)
Would you prefer:	Private HomeNursing HomeHospitalAssisted Living Center
Have experience with:	Peg TubesCathetersHoyer LiftsLifting Patients (with little/no asst.)
	Paralyzed PatientsPsych PatientsAlzheimer's PatientsDementiaHospice Care
	Parkinson'sColostomy BagDiabetes CareTrach TubesPlacing Patients in Wheelchair
	Blood Pressure Monitoring (manual/digital)Contagious DiseasesOxygen Care
Would you perform:	ErrandsEmpty bedside CommodesEscort to Appointments
	BathMeal PreparationLight 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			YesNo
Community College			YesNo
Technical Training School			YesNo
College			YesNo

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/ASPANISHFRENCHOTHER

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

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

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

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

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)

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? YesNo	Do you have a vehicle? YesNo		Is the vehicle a:
Are you interested in being a child care provider?YesNo		If so are you Child/Infant CPR Certified?YesNo
Will you work with cats on the premises?YesNo		If no, why not:
Will you work with dogs on the premises?YesNo		If no, why not:
Have you ever been convicted of a crime other than a minor traffic violation? YesNo
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?

Serving Greater New Orleans

New Orleans, LA

(504) 486-5044

help@dependablecare.net

Business Hours: 24/7

8am - 8pm Access Coordinators Available

Contact Information

Dependable In Home Care Location

Please indicate the locations in which you are able to be referred: (Check all that apply)
Abita SpringsChalmetteCovingtonKennerLacombeMadisonvilleHammondMandevilleMetairieNew OrleansSlidellWestbankLaplacePicayune, MSMississippi (certain areas)