Caregiver Application — Coast To Coast Compassionate Care

Personal Info

Experience

References

Agreement

👤 Personal Information

📍 Which location are you applying to? * Choose the city/area where you want to work.

First Name *

Last Name *

Date of Birth *

Social Security # (last 4 only)

Phone *

Email *

Home Address *

City *

State

ZIP

Do you have reliable transportation? *

Do you have a valid driver's license?

Are you legally authorized to work in the US? *

Languages spoken

📞 Professional References

Please provide at least 2 professional references (former employers, supervisors, or clients). Personal/family references are not accepted.

Reference 1 *

Full Name *

Relationship *

Phone *

Reference 2 *

Full Name *

Relationship *

Phone *

Reference 3 (optional)

Full Name

Relationship

Phone

Have you ever been convicted of a felony or misdemeanor? * A conviction does not automatically disqualify you. We evaluate each situation individually.

📋 Agreement & Certification

Independent Contractor Agreement

I understand and agree that if selected, I will be engaged as an independent contractor (1099) and not as an employee of Coast To Coast Compassionate Care. As an independent contractor, I am responsible for my own taxes, including self-employment tax. I will not be entitled to employee benefits such as health insurance, workers' compensation, unemployment insurance, or paid time off. I understand that I have the right to work for other clients, provided there is no conflict of interest. I agree to maintain the confidentiality of all client information and to comply with HIPAA privacy standards. I understand that Coast To Coast Compassionate Care may terminate this agreement at any time, and I may also terminate it at any time, with reasonable notice when possible.

I understand and agree to the independent contractor terms above. *

Background Check Authorization

I authorize Coast To Coast Compassionate Care to conduct a background check, including criminal history, as part of the application process. I understand that this information will be used solely for employment screening purposes and will be kept confidential. I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts may result in denial of employment or termination.

I authorize a background check and certify all information is accurate. *

Electronic Signature — Type your full name to sign * By typing your name above you are electronically signing this application.

Today's Date

How did you hear about us?

🎉

Application Submitted!

Thank you for applying to Coast To Coast Compassionate Care. We'll review your application and reach out within 48 hours to schedule an interview.

👩‍⚕️ Apply to Be a Caregiver

Application Submitted!