Caregiver Application Form

Personal Information
*
*
*
*
*
*
*
*
*
*
*
*
*

Educational Background  New Educational Background

Employment History  New Employment History

Please provide your latest employer information below.

Completion of a minimum of one skill/preference is required.

Skills/ Preferences

Availability
Cooking Skills
Experience
General
Language
Level of Ability
Personal Care
Pets
Skill Type
Transportation
Vehicle Type

References   New Reference

Miscellaneous Questions

Q.) Caregiver Transportation
Q.) Transporting Clients
Q.) Clients not willing/able to work with
Q.) Duties not willing/able to perform
Q.) Have you ever been investigated for abuse, neglect, or domestic violence? If "yes" explain:
Q.) If "yes" to question #5 please explain:
Q.) Indicate Days and Hours Available for Work
Q.) Consent to Criminal Background Check As a condition of employment with Empathetic Hearts Home Care, I understand that I am required to undergo a comprehensive national criminal background check through a state-approved vendor (Checkr or Safe Hire), in accordance with Indiana Code IC 16-27-2-5. I understand that convictions including but not limited to sex crimes, exploitation of endangered adults, child abuse or neglect, murder, manslaughter, theft, or battery will result in disqualification from any direct care role.

* Caregiver Signature

© Copyright 2025, Developed and Maintained By CareSmartz360