Caregiver Application

HELPMEWAKA HOME CARE

Caregiver Application & Credential Submission Form

Thank you for your interest in becoming a Helpmewaka Caregiver. Please complete all sections accurately. Incomplete applications will not be processed.

SECTION 1: PERSONAL INFORMATION

Full Name *

Date of Birth *

Gender *

Nationality *

Home Address *

Phone Number *

Email Address *

Preferred Comm. Method

Next of Kin (Name & Contact) *

SECTION 2: POSITION APPLYING FOR

Select Role(s) *

Non-Medical Caregiver Licensed Nurse (RN/LPN/Equivalent) Live-in Caregiver Non-Live-in Caregiver

Available Start Date *

Preferred Work Type

Willing to work Monday–Friday schedule?

Yes No

Willing to work extended hours if required?

Yes No

SECTION 3: EDUCATION & PROFESSIONAL TRAINING

Highest Level of Education *

Institution Attended *

Field of Study

Year of Graduation

Relevant Professional Certifications

SECTION 4: PROFESSIONAL LICENSE (IF MEDICAL)

License Type (RN / LPN / Other)

License Number

Issuing Authority

License Expiry Date

Have you ever had a license suspended or revoked? (Yes / No - Explain)

SECTION 5: WORK EXPERIENCE

Most Recent Employer

Position Held

Dates of Employment

Reason for Leaving

Previous Caregiving Experience (Describe)

Experience with elderly patients?

Yes No

Experience with post-surgery patients?

Yes No

Experience with dementia/memory loss?

Yes No

Experience with wound care?

Yes No

SECTION 6: SKILLS & COMPETENCIES

Select Skills you possess:

Medication administration Vital signs monitoring Wound care Injection administration Mobility assistance Personal hygiene support Meal preparation Companionship support Record keeping and documentation

Other relevant skills (Specify):

SECTION 7: BACKGROUND & COMPLIANCE

Have you ever been convicted of a crime? (Yes / No - Explain)

Willing to undergo a background check?

Yes No

Willing to undergo periodic credential verification?

Yes No

SECTION 8: REQUIRED DOCUMENTS

Mandatory (All Applicants)

Government-issued ID

Choose ID File PDF, PNG, JPG, JPEG (Max 5MB)

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Updated CV/Resume

Choose CV/Resume PDF, DOC, DOCX (Max 5MB)

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Two Professional References

Choose References File PDF, DOC, DOCX (Max 5MB)

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Police Clearance / Background Check

Choose Clearance File PDF, PNG, JPG, JPEG (Max 5MB)

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CPR Certification

Choose CPR Certificate PDF, PNG, JPG, JPEG (Max 5MB)

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First Aid Certification

Choose First Aid Cert PDF, PNG, JPG, JPEG (Max 5MB)

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Passport-sized Photograph

Choose Photo PNG, JPG, JPEG (Max 5MB)

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Medical Applicants Only

Nursing License

Choose License File PDF, PNG, JPG, JPEG (Max 5MB)

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License Verification

Choose Verification File PDF, PNG, JPG, JPEG (Max 5MB)

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Continuing Ed Certificates

Choose Certificates File PDF, PNG, JPG, JPEG (Max 5MB)

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Malpractice Insurance

Choose Insurance File PDF, PNG, JPG, JPEG (Max 5MB)

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Specialized Certifications

Choose Special Certs PDF, PNG, JPG, JPEG (Max 5MB)

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APPLICATION PROCESS

1 Complete personal and role details
2 Provide credentials & work experience
3 Upload mandatory document files
4 Sign consent & submit for review

Important Note

Please ensure all uploaded files are clear and readable. Incomplete applications or blurry document scans cannot be processed and will be disqualified.

DECLARATION & SIGNATURE

I confirm that all information provided is accurate and truthful. I understand that falsification will result in disqualification. I consent to credential verification & background checks.

Electronic Signature *

Date *

Caregiver Application

HELPMEWAKA HOME CARE

Caregiver Application & Credential Submission Form

SECTION 1: PERSONAL INFORMATION

SECTION 2: POSITION APPLYING FOR

SECTION 3: EDUCATION & PROFESSIONAL TRAINING

SECTION 4: PROFESSIONAL LICENSE (IF MEDICAL)

SECTION 5: WORK EXPERIENCE

SECTION 6: SKILLS & COMPETENCIES

SECTION 7: BACKGROUND & COMPLIANCE

SECTION 8: REQUIRED DOCUMENTS

Mandatory (All Applicants)

Medical Applicants Only

APPLICATION PROCESS

Important Note

DECLARATION & SIGNATURE

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