Caregiver Registration Home > Caregiver Registration Thank you for your interest in becoming part of our database at Prime Caregivers. Please complete and submit this application so we can begin the process of matching you with a client. Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate Of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Phone *Email *Can Prime Caregivers contact you?Yes, Prime Caregivers can contact meNo, Prime Caregivers may not contact mePrime Caregivers is a Caregiving Referral agency. Contact will be for referral only. We do not directly employ any Caregivers.Have you been employed by Prime Caregivers before?YesNoYour preferred area of work?Los Angeles CountyOrange CountyRiverside CountySan Bernadino CountyCheckboxesCentral Los AngelesWest Side/South BaySan Fernando ValleyLong Beach/562San Gabriel Valley/ Pasadena AreaCheckboxesSouth Orange CountyAnaheimGarden Grove/ HB/ Seal BeachHow did you hear about Prime Caregivers?ReferralNewspaperJob FairGoogle SearchFacebookOtherOther SourceEmergency Contact information:List 2 individuals we can contact in case of an emergencyEmergency Contact *Relationship *Phone Number *2nd Emergency Contact Name * Relationship *e.g., Spouse, Brother, Friend, etc. Phone Number *Work PreferencesWhich position you are most interested in: *Live- In CaregiverHourly CaregiverHow many days per week are you available to work?12345How many hours per shift are you available?4hrs8hrs12hrs24hrs/live-inWhat days and times are you available to work?Monday - DayMonday - NightTuesday - DayTuesday - NightWednesday - DayWednesday - NightThursday - DayThursday - NightFriday - DayFriday - NightSaturday - DaySaturday - NightSunday - DaySunday - NightAll/AnyDay (5am-5pm), Night (5pm- 5am),Client PreferencesYou prefer to work with?Male Clients OnlyFemale Clients OnlyBothYou prefer to work with?One clientMultiple clientsAre you allergic to the following?CatsDogsFragrancesSmoke/cigarettesOther AllergiesAre you able to work in a “smoking” home?YesNoAdditional InformationOther languages spoken:List other special skills or experiences that you have used or have come across in homecare? For example: Sewing, beautician, barbering, gardening, cooking, singing, etc. Driving and areas of workPlease select the areas where you are willing to work:Do you drive?YesNoHow many miles are you willing to commute?Will you be able to use a car to drive the ciient around?YesNoDriving for the client usually increases hourly/live in payCertificationsProvide copies of certifications during the hiring process.Are you certified for CPR?YesNoDo you have First Aid training?YesNoAre you currently certified as a:Registered CaregiverCNALVNRNTraining and EducationTraining and EducationHigh SchoolField of study?Did you graduate?YesNoCollege or other EducationField of Study?Did you graduate? YesNoDo you have Training related to Caregiving or Healthcare? If yes, please explain.If yes, who hired you?Caregiving Referral AgencyDirect Hire by Home Health Care AgencyDirect Hire by ClientotherWork ExperiencePlease list your most recent employers firstEmployer or Patients nameAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSupervisor's Name & PhoneStart DateEnd DatePosition heldWhat was your schedule? Live In or Live out?How many patients did you care for in a shift?Duties and Responsibilities:Reason for leaving:Request for Reference Information CompletedYesNoWork Experience 2Employer (Client's Name)AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSupervisor's Name & PhoneStart DateEnd DatePosition heldScheduleHow many patients did you care for in a shift?Duties and Responsibilities:Reason for leavingRequest for Reference Information CompletedYesNoUpload ResumeI certify that everything In this application is true and to the best of my knowledge. *YesDo you give Consent for Prime Caregivers to review and forward your application when a client is matched? *YesNoPrime Caregivers is a Referral Agency. Prime Caregivers does not employ any Caregivers. All information obtained is stored in our secure database and will be matched to clients with no discrimination.CommentSubmit