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Home
About Us
Caregivers
Staff
Board of Directors
Partnerships & Sponsors
Training
History
FAQs
Services
In-Home Care
Equipment Loan
Health Navigation
News & Events
Who We Help
Support Us
Donate Now
Monthly Donations
Planned Giving
Get Involved
Donate Time
Donate Equipment
Become a Caregiver
Volunteer Stories
Contact Us
Professional Caregiver Application
Date of Application
Full Name
Address with ZIP code
Mobile Phone
Alternative Phone
Email
EMERGENCY CONTACT: Name, relationship, phone #s
Date of Birth
Gender
Female
Male
Other
Bilingual (CHC caregivers must be fluent in English)
Spanish
Other
Veteran
Yes
No
Ethnicity
Caucasian
Hispanic
Native American
African American
Asian
Other
Smoker
Yes
No
Are you credentialed in a health-related profession? (Doctor, RN, CNA, other?)
What, if any, experience have you had in health-related fields, as a professional or volunteer? Please explain.
What kinds of volunteer experience have you had apart from caregiving?
What caregiving services are you able to offer? (Please check all that apply)
Companionship
Errands
Grocery Shopping
Meal Prep
Light housework
Laundry
Driving to Appointments
Transfers (training provided)
Bed Care
Showering
Toiletting
Overnight Care
Dementia Care
In-hospital Care
Hospice/End-of-Life Care
Working with children
What skills or personal interests do you have that may be of interest to clients of CHC?
What personal qualities do you bring to the CHC caregiving experience?
Do you have any health issues that may limit your service as a caregiver?
Current Employment: list names of employers, time at each position, and duties at your last two jobs. Please attach a resume for further job history.
Please provide two professional references: name, relationship, phone number.
I agree to CHC checking my references and conducting a background check.
Yes
No
CHC asks all of our paid caregivers to give back with 4-6 hours of volunteer caregiving per month. Can you make that commitment?
Yes
No
What is your availability?
4-8 hour shift, 2 days per week
4-8 hour shift, 3-4 days per week
Available 5 days a week
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