In-Home Caregiver Application

Location: 661A Church Road, Orrtanna, PA

Pay: $20.00/hour

Currently we have Tuesday evening shifts (6:00 pm - 10:00 pm) available.

Each month we also have various weekend morning and evening open shifts. Below you can select the shifts that you may be available to work (there is no guarantee that shifts will be available to fill for the days selected).

If you have any questions, please contact: Lori McDaniel @ 717-480-8243 (call or text)

A BACKGROUND CHECK WILL BE PERFORMED

If you are a suitable candidate, additional information will be required to conduct a criminal history background check through the PA State Police.

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Area CodePhone Number

E-mail

Date Available to Start

Date

I am available for the following shifts (most open shifts are in the evening)

Are you currently employed?

If Yes, may we contact your current employer?

Are you legally authorized to work in the U.S.?

Client/Employer Name

Client/Employer Contact Number

Area CodePhone Number

Position

Client/Employer Name

Position

Phone Number

Area CodePhone Number

Name

Relationship

Client, Employer, Co-worker

Phone Number

Area CodePhone Number

Name

Relationship

Client, Employer, Co-worker

Phone Number

Area CodePhone Number

In-Home Caregiver Application

Personal Information

Availability

Employment & References

Current Client/Employer

Former Client/Employer

References