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Veterans' Program

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	Personal info
	First Name:
	Last Name:
	Street Address:
	City:
	State:
	Zip:
	Home Phone:
	Cell Phone:
	Number in case of emergency:
	E-Mail:


	What type of position are you applying for (Check all that apply)?	Live-in Hourly

	Referred by
	Newspaper Ad (Specify paper):

	Legal Record
	Have you ever been convicted of a felony?	Yes No
	Have you ever been convicted of a misdemeanor?	Yes No
	If Yes to either, please provide details.
	By clicking here, you authorize Sheridan Care, Inc. to complete your background check

	Transportation
	Do you drive?	Yes No

	Do you have your own vehicle?	Yes No
	Make and model of your vehicle:

	Availability
	How many hours would like to work per week?
	What times are you available to work?
	May we call you at the last minute in case of an emergency need?	Yes No

	Education
	Degrees/Certificates:
	Special Skills/Courses:

	Experience
	Please list any training or experience you have working with the elderly:
	What would you like most about working with the elderly?

	Skills	Please indicate whether you have assisted with or performed the following tasks for seniors.
	Companionship:	Yes No
	Bathing/Dressing:	Yes No
	Bathing/Full Assist:	Yes No
	Grooming:	Yes No
	Incontinence:	Yes No
	Transfer Assist:	Yes No
	If Yes:	Min Mod Max
	Laundry:	Yes No
	Alzheimer's Experience:	Yes No
	Driving:	Yes No
	Vacuuming:	Yes No
	Dusting:	Yes No
	Dementia Experience:	Yes No
	Housekeeping:	Yes No
	Incontinent/Full Assist:	Yes No
	Bed Linen Changes:	Yes No
	Grocery Shopping:	Yes No
	Rate Cooking:	1 2 3 4 5
		(1=poor, 5=excellent)
	Medication Reminders:	Yes No
	Lifting:

	References
	Please list at least 3 business references with names and phone numbers:

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