Online Caregiver Application Form | Caregivers, Nannies & Home Support Workers Placement Agency since 1998.

A. Personal Info:

First Name *

Middle Name

Last Name *

Present Address *

City *

Province *

Country *

Postal Code *

Email Address *

Home Phone *

Cell Phone *

Work Phone *

Date of Birth *

Age *

Height *

Weight *

Marital Status *

# of Children *

Ages of your Children *

Religion

Passport No.

Passport Issue Date

Passport Expiry Date

SIN

Driver License #

DL Issue Date

DL Issue Country

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B. Place of Birth:

City *

Province *

Country *

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C. List the Languages that you can proficiently:

Speak *

Read *

Write *

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E. Employment history related to the Caregiver position that you are applying:

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Present or Last Employer

Employer’s full name

Employer’s Phone No.

Employment City

Employment Country

No. of Children in your care

No. of Elderly in your care

Age of kids/eldery cared for

Start Date

End Date

Reason for leaving the employer

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Previous Employer No.2

Employer’s full name

Employer’s Phone No.

Employment City

Employment Country

No. of Children in your care

No. of Elderly in your care

Age of kids/eldery cared for

Start Date

End Date

Reason for leaving the employer

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Previous Employer No.3

Employer’s full name

Employer’s Phone No.

Employment City

Employment Country

No. of Children in your care

No. of Elderly in your care

Age of kids/eldery cared for

Start Date

End Date

Reason for leaving the employer

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F. Educational background:

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High School

Degree you obtained *

Specialization you obtained *

Graduation Diploma *

Grade Completed *

No. of Units

Start Date *

End Date *

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College or University

Degree you obtained

Specialization you obtained

Graduation Diploma

Grade Completed

No. of Units

Start Date

End Date

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Certificates & Trades

Degree you obtained

Specialization you obtained

Graduation Diploma

Grade Completed

No. of Units

Start Date

End Date

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D. For what position are you applying?

Live In *

Live Out *

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G. Past and present work experience

1. Do you have experience in taking care of Elderly, Handicap or Disabled person(s)? *

2. Do you have experience in taking care of Infants & Toddlers (0 to 2 years old)? *

3. Do you have experience in taking care of Children ages 2 to 10 years old? *

4. Do you have experience in changing diapers & preparing food for toddlers? *

5. Do you have experience in cooking, baking & serving meals for the family? *

6. Do you know how to play indoor & outdoor sports - soccer, biking or swimming? *

7. Do you like to teach how to read, write, count, colour, draw, and play games? *

8. Are you willing to take the kids to parks, recreational centers & playgrounds? *

9. Do you consider yourself strong & secure enough to work without supervision? *

10. Can you do emergency or unexpected work or babysitting, if the parents ask you? *

11. Do you like to travel?
*

12. If necessary, would you travel with the employer? *

13. Do you like pets (dogs, cats, fish or birds)? *

14. Can you take care of pets? *

15. Do you smoke?
*

16. Do you have any allergies? If yes, please describe. *

17. Have you had any illnesses in the past 2 years? *

18. Have you had any back injuries in past 5 years? *

19. Do you have a CPR & First Aid certificate?
*

20. When did you complete the CPR & First Aid certificate?

21. Have you completed a 6 month Caregiver Course? *

22. When did you complete the 6 month Caregiver Course?

23. When was your last Work Permit issued? *

24. When does your work permit expire? *

25. Have you ever been convicted in a court of law? *

26. Do you have police clearance from the countries where you lived and worked? *

27. When will the contract with the present employer expire? *

28. When you will be able to end your job with the present employer? *

29. When are you available to start working? *

30. What is your salary expectation per month?

31. When did you begin your career as a Caregiver / Nanny / Home Support worker? *

32. Do you have a driver's licence from your country of origin or from Canada? *

33. What contract length do you prefer? *

34. How do you spend your free time? *

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H. Experience

Please describe how you managed a day of work for one of the previous families you worked for. *

Please give examples of your work experience as a Nanny/Caregiver/Nurse/Home Support Worker/Teacher. *

What duties did you had & how you handled them in various critical situations. *

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I. Friend or Relative living in Canada:

Full Name

Address

City

Relationship

Phone Number

Email Address

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J. Personal info about your family from your country of origin

Address

City

Province/State

Country

Religion

Home Phone

Cell Phone

Father's Occupation

Mother's Occupation

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Document Upload

Passport

Visa

Work Permit

Photo with children/elderly

Documents

Certificate

Resume

Other #1

Other #2

Agreement *

By submitting this form, I agree to the terms and conditions.

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