APPLICATION FOR A LIVE IN CAREGIVER POSITION IN CANADA

NAME : _____________________________________

DATE : _____________________________________

Home Address : __________________________________________________________

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Present Address : _________________________________________________________

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Telephone Number (Including Area Code) ___________________________

Fax Number (Including Area Code) ________________________________

Indicate position desired (children, elderly, disabled) ____________________

Highest education attainment ________________________________________________

Diploma/Degree obtained __________________________________________________

Additional Education and Training ___________________________________________

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Date of Birth ___________________ Place of Birth ________________________

Height ___________ Weight ___________

Nationality _______________________ Religion _______________________

What languages do you speak ? ______________________________________________

English Skills :

Spoken Very Good ______ Good _____ Fair _____ None _____

Reading Very Good ______ Good _____ Fair _____ None _____

Written Very Good ______ Good _____ Fair _____ None _____

Marital Status _________________ Number of Children __________ Ages ______

Do you have any allergies ? _____________________________________________

Do you have any physical or mental illnesses ? _________________

If yes, please state the nature of the illness: ____________________________

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How is your general health ? _____________________________________________

What is your passport number ? _________________________________

Expiry Date _______________________

When does your present working visa expire ? _______________________________

Date available for employment ____________________________________________

Can you swim ? ___________ Do you smoke ? ___________

Do you drink alcohol ? ___________

Do you drive ? ___________ Are you willing to learn ? ___________

Hobbies ________________________________________________________________

Will you work with domestic animals (dogs/cats) _______________________________

Can you cook ? _______ What types of food ? __________________________________

Have you taken a first aid course ? _______________________________

Are you willing to work for a single parent ? _______________________

How many children are you willing to take care of ? _________________

Do you have experience with the elderly ? _________________________

Can you administer medication ? ________________________________

What activities will you do with children ? ___________________________________

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What outdoor sports will you do with children ? _______________________________

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What kind of food would you feed children ? ___________________________________

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Please indicate beside each of the following which duties you can perform.

Please indicate your skill level with the following tasks using the following words :

Satisfactory / Good / Excellent

Housekeeping _____________________ Care of babies (infants) __________________

Cooking __________________________ Changing diapers ______________________

Laundry __________________________

Preparation of Formula (baby bottle) _________________________

Ironing ___________________________ Feeding baby _________________________

Elderly Care _______________________ Grocery shopping _____________________

Caring for disabled __________________

Would you be willing to work a 6 day work week ? _______________

Which age group do you prefer to care for ? _____________________

Please explain what makes you a good candidate for a caregiver

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Please attach a letter of reference to this application.

You must have a college level education (72 units).

You also require a minimum of 6 months of full time training in a related field to the position you are seeking.

I, the undersigned applicant hereby certify and declare that all of the above information is true and that aside from being denied entrance into Canada, I have complete intention of working for an employer in Canada and will not withdraw my application.

Applicant’s Signature : _____________________________________

Date : _______________________