General Caregiver Application

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Our Quality
Our Nurses And Therapists
Our Caregivers
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Become A Caregiver
English
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Which Serenity Location are you applying to?*
Which Serenity Branch are you applying for?
Which Serenity Branch are you applying for?
Which Serenity Branch are you applying for?
Which Serenity Branch are you applying for?
Which Serenity Branch are you applying for?
Which Serenity Branch are you applying for?
Which Serenity Branch are you applying for?
Full Name*
First Name Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email*
Date Available*
MM slash DD slash YYYY
Have you previously been employed with our organization?*
- Yes
- No
Are you authorized to work in the US?*
- Yes
- No
Have you ever been convicted of a felony offense?*
- Yes
- No
(Note: A conviction will not necessarily disqualify you from employment.)
Have you completed a background check within the past 12 months?*
- Yes
- No
Do you have any language needs?*
- Yes
- No
If yes, please provide us with more information.
Background check view section:
Full Name*
First Name Last Name
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Other Names Used*
Telephone*
States Where You Have Lived*
Gender*
- Male
- Female
Race*
Race
- A Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander.
- B Black or African American(Not Hispanic or Latino)
- C Hispanic or Latino(Mexican, Puerto Rican, Cuban Central or South American, or other Spanish culture or origin)
- D American Indian, Eskimo, or Alaskan native, or person having origin in any of the 48 contiguous states of United States or Alaska who maintains cultural identification through tribal affiliation or community recognition.
- E Of undeterminable race. Of Untold mixture.
- F Caucasian(not Hispanic or Latino)
Height*
Weight*
Hair Color*
Eye Color*
Have you even had an administrative finding of Abuse, Neglect or Theft? If "Yes", give full details state. Continue on back if more space is needed.*
- Yes
- No
Full Details
Have you ever been convicted of criminal offense other than minor traffic violation(do not include convictions that have been expunged, sealed or adjudicated delinquent)? If "Yes", give full details of each offense and the state in which convicted. Continue on back if more space is needed.*
- Yes
- No
Full Details
Select all applicable skills and preferences that reflect your experience and comfort level.
Client Care Experience*
- Dementia Care Experience
- Hospice Care Experience
- Incontinence Care Experience
Mobility Assistance*
- Experience with Transfers
- Gait Belt Experience
- Hoyer Lift Experience
Environmental Preferences*
- Comfortable working in homes where clients smoke
- Comfortable around pets
Pets
- OK with Cats
- OK with Dogs
Transportation
Do You Drive?*
- Yes
- No
If yes, can you provide:*
- Valid Driver’s License
- Proof of Car Insurance
Education
Education*
- High School Graduate
- College Degree
- Postgraduate Education
School*
Degree Received*
Certifications And Credentials
Please check all that apply*
- Certified Nursing Assistant (CNA) License
- CPR Certification
- First Aid Certification
- Tuberculosis (TB) Test
- State ID Card
Other Skills & Qualifications
Please list any additional relevant skills, languages, or certifications:*
Employment History
Employer
Date Employed
Supervisor
Supervisor Phone Number
Company Address
Resume & Credentials
Upload your Resume*
Max. file size: 1 GB.
Upload your credentials
Drop files here or

Accepted file types: jpg, pdf, doc, Max. file size: 1 GB.
References
Name*
First Name Last Name
Job title*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*

6640 W. Touhy Ave

Niles, IL 60714

United States

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Serenity Home Healthcare was created with the hope of providing a caring and compassionate hand to individuals in need.

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Is the Client located within Illinois?

Yes

No

Refer A Client

Name of Potential Client

Date of Birth of Potential Client

Street Address of Potential Client

City

State

Zip Code

Contact Number

Requires Assistance With:

Is there a family member or friend who would like to be the caregiver for this client?

Refer A Client

Name of Potential Client

Date of Birth of Potential Client

Street Address of Potential Client

City

State

Zip Code

Contact Number

Requires Assistance With:

Is there a family member or friend who would like to be the caregiver for this client?

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General Caregiver Application

Race

Select all applicable skills and preferences that reflect your experience and comfort level.

Transportation

Education

Certifications And Credentials

Other Skills & Qualifications

Employment History

Resume & Credentials

References

Is the Client located within Illinois?